Citation Nr: 21065003 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 12-08 010A DATE: October 22, 2021 ORDER Entitlement to an initial 100 percent disability rating for schizoaffective disorder, depressive type, with alcohol use disorder, and unspecified personality disorder, is granted. From January 11, 2011, entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s) is granted. Prior to January 11, 2011, entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities, for SMC purposes, is dismissed as moot. REMANDED Entitlement to service connection for an eye condition is remanded. Entitlement to compensation under 38 U.S.C. § 1151 for vision loss is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the symptoms and impairment caused by the Veteran's service-connected psychiatric disability more nearly approximates total occupational and social impairment. 2. From January 11, 2011, the Veteran is in receipt of a total (100 percent) rating for his service-connected psychiatric disability and has additional separate and distinct service-connected disabilities ratable at 60 percent or more. 3. The Veteran's service-connected psychiatric disability is being awarded a total (100 percent) rating for the entire claim period based in part on a finding of total occupational impairment, leaving no part of the claim period where the schedular rating is less than total. The Veteran does not allege he was unable to secure or follow a substantially gainful occupation due to his service-connected tinnitus and fracture residuals of the third digit of the right foot prior to January 11, 2011 and he is in receipt of SMC under 38 U.S.C. § 1114(s) from January 11, 2011; thus, the issue of entitlement to a TDIU is rendered moot for the entire claim period. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial 100 percent rating for his service-connected psychiatric disability are met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2020). 2. From January 11, 2011, the criteria for SMC pursuant to 38 U.S.C. § 1114(s) are met. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350 (2020). 3. Entitlement to a TDIU, to include for purposes of SMC, is dismissed as moot. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. § 20.101 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1977 to February 1981. These matters come to the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision which granted service connection for posttraumatic stress disorder (PTSD), evaluated at 10 percent, effective May 6, 2010; and a December 2011 rating decision which declined to reopen a claim of entitlement to service connection for an eye condition on the basis that new and material evidence had not been submitted. In June 2016, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing. A copy of the transcript is of record. In August 2016, the Board found that new and material evidence had been received to reopen the claim of entitlement to service connection for an eye disability. The Board also found that entitlement to a TDIU had been raised as part of the Veteran's increased rating claim for his service-connected psychiatric disability pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), and remanded all claims for further development. In August 2020, the Board remanded the matters for further development, to include obtaining new VA examinations and medical opinions and outstanding VA treatment records. In a June 2021 rating decision, VA corrected the Veteran's psychiatric diagnosis from PTSD to schizoaffective disorder, depressive type, with alcohol use disorder and unspecified personality disorder, and assigned an initial disability rating of 70 percent prior to May 7, 2021, and a 100 percent evaluation thereafter. As the grant of an initial 70 percent evaluation prior to May 7, 2021 does not represent a maximum grant of the benefit sought on appeal, the Veteran's increased rating claim prior to May 7, 2021 remains pending before the Board. The Board notes that claims of entitlement to service connection for a lumbar spine disability, bilateral lower extremity radiculopathy, and bilateral knee disabilities were also on appeal and remanded by the Board in August 2020. VA granted service connection for a lumbar spine disability, bilateral lower extremity radiculopathy, and bilateral knee disabilities in an April 2021 rating decision. As the grant of service connection represents a maximum grant of the benefit sought on appeal for those claims, the claims are no longer before the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Within that context, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App. 119 (1999). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The standard of proof to be applied in decisions on claims for veteran's benefits is set forth in 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. 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 an initial disability rating in excess of 70 percent for schizoaffective disorder, depressive type, with alcohol use disorder and unspecified personality disorder prior to May 7, 2021. The Veteran contends that an increased rating is warranted for his service-connected psychiatric disability. Initially, VA granted service connection for posttraumatic stress disorder (PTSD) with depressive disorder, not otherwise specified, and anxiety disorder. However, January 2020 and June 2021 VA examination reports reflect that the Veteran does not meet the diagnostic criteria for PTSD and has not meet the diagnostic criteria for PTSD at any point during the appeal period. Rather, the Veteran meets the diagnostic criteria for schizoaffective disorder, depressive type; alcohol use disorder, severe, in long-term remission; and unspecified personality disorder, which have been found to be related to service. As such, the Board has updated the Veteran's diagnosis to reflect his currently diagnosed psychiatric disability. The Veteran's psychiatric disability is evaluated at 70 percent prior to May 7, 2021, and at 100 percent thereafter, under 38 C.F.R. § 4.130, Schedule of Ratings Mental disorders, Diagnostic Code (DC) 9211. 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 adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Under the applicable rating criteria, a 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Finally, a 100 percent disability rating, the maximum available, is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 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 (Fed. Cir. 2013). 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, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. 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 rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. This appeal was certified to the Board after August 4, 2014; thus, the DSM-5 applies, and GAF scores are inapplicable. 80 Fed. Reg. 14, 308 (March 19, 2015). When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; the analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan, 16 Vet. App. at 442-43. The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation but are not meant to be exhaustive. Id. Turning to the evidence of record, an April 2010 VA mental health treatment record reflects the Veteran reported having PTSD symptoms and nightmares about incidents during service. Upon examination, he appeared alert and oriented and was cooperative. His mood was not depressed but affect was slightly anxious. He denied suicidal ideation or psychosis. The clinician provided a diagnosis of PTSD with nightmares and prescribed medication. A June 2010 VA mental health treatment record reflects the Veteran reported having PTSD nightmares despite medication. He presented as alert and oriented, and cooperative. His mood was not depressed but his affect was blunted. He denied suicidal ideation or psychosis. An August 2010 VA examination report reflects the Veteran reported nightmares, intrusive daily thoughts about his experiences during service, and avoidance of triggers that reminded him of his time in service. He reported a previous diagnosis of schizophrenia. Upon examination, the Veteran was neatly groomed and appropriately attired. Eye contact was good, but the Veteran did not blink. He was cooperative and speech was linear and within normal limits but intense. He reported thoughts of suicide in the past without plan or intent, but none recently. He was oriented but would not attempt testing for abstract thought process. The Veteran demonstrated depression and appeared anxious but minimized his anxiety during the examination. Thought processes and communication were adequate but affect was mildly inappropriate. He did not have difficulty with activities of daily living but was extremely isolated. The examiner provided diagnoses of posttraumatic stress disorder noncombat; depressive disorder, not otherwise specified and most likely related to his PTSD; anxiety disorder secondary to PTSD; and personality disorder not otherwise specified. The examiner indicated that the Veteran's PTSD signs and symptoms required continuous medication but were transient or mild and decreased work efficiency and ability to perform occupational tasks during periods of significant stress. VA mental health treatment records dated in September 2010 to September 2011 reflect the Veteran reported recent DUIs and court-ordered psychiatric treatment. He continued to report active PTSD symptoms with nightmares. Upon examination, he appeared alert and oriented and casually dressed. He maintained eye contact, but his demeanor ranged from cooperative to suspicious. Mood ranged from dysphoric and depressed to not depressed, and affect ranged in description, including blunted, anxious, or full. Speech was normal without evidence of thought disorder, mania, or suicidal or homicidal ideation. Concentration was fair, memory was not impaired, judgment was appropriate, but insight was poor. His clinician noted that attempts to expand on mental health problems were met with resistance and the Veteran lacked insight on these issues. The Veteran was challenging to redirect and had a difficult time describing his symptoms. The assessment in September 2011 was rule out major depressive disorder, alcohol abuse, PTSD, and rule out antisocial personality disorder. A December 2011 VA examination report reflects a history of PTSD but current diagnoses of antisocial personality disorder; personality disorder, not otherwise specified; alcohol dependence, early partial remission; mood disorder, not otherwise specified; and anxiety disorder, not otherwise specified. The examiner indicated that it was possible to differentiate what symptoms were attributed to each diagnosis. Specifically, the Veteran's cognition and inability to relate to and engage with others in meaningful ways were due to his personality disorder; alcohol abuse was due to his alcohol dependence; and anxiety and depression were due to his anxiety and depressive disorders and related to his personality disorder. The examiner extensively noted the inconsistencies in the Veteran's reported and documented history and based on this and his personality disorder, indicated that there was not enough evidence that the Veteran actually met the criteria for a diagnosis of PTSD or schizophrenia. The examiner indicated that even if the Veteran had PTSD, it did not result in any social or occupational impairment; however, his personality disorder resulted in total occupational and social impairment based on his inability to function within reasonable societal expectations. The examiner found symptoms of depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, disturbances in motivation and mood, and obsessional rituals which interfered with routine activities. VA mental health treatment records dated in March and September 2012 reflect the Veteran reported depression, anxiety, and irritability, but normal appetite and improved sleep on medication. Upon examination, he was alert and oriented with good eye contact, neatly groomed, and cooperative. Speech ranged from poor but without slurring to spontaneous and coherent. He denied suicidal and homicidal ideation and hallucinations. Mood was dysphoric, irritable, and rude, and affect ranged from suspicious to broad and congruent. Memory appeared unimpaired, judgment was appropriate, and insight ranged from poor to grossly intact. VA mental health treatment records dated in November 2012 through August 2013 reflect the Veteran reported intermittently hearing voices and paranoia that were improved on regular medication. He reported his appetite was normal and sleep was improved on medication. Upon examination, he was alert and oriented with good eye contact, fairly groomed, and cooperative. Speech was spontaneous and coherent. He denied suicidal and homicidal ideation. Mood ranged from dysphoric to neutral, and affect was fairly broad and congruent. Memory, insight, and judgment appeared grossly intact. The assessment in November 2012 was depressive disorder, not otherwise specified; psychotic disorder, not otherwise specified; PTSD by history; and alcohol dependence with episodic binge pattern reported. VA mental health treatment records dated in October 2013 through March 2015 reflect the Veteran reported doing well, that his medications were working, he had quit drinking, and his appetite and sleep quality varied. He reported depression, anxiety, and irritability. Upon examination, he appeared fairly groomed and cooperative with good eye contact. Mood ranged from subdued and less dysphoric to neutral and calm, while affect was fairly broad and congruent. Speech was spontaneous and coherent. Thoughts ranged from better organized although circumstantial to grossly organized and while he was sometimes ruminative, there were no signs of delusions, paranoia, acute hallucinations, or overt thoughts. He denied suicidal and homicidal ideation. Memory, insight, and judgment were grossly intact. The March 2015 assessments were unspecified depressive disorder, unspecified personality disorder, unspecified psychotic disorder, economic stressors, PTSD by history, and alcohol use disorder, moderate to severe, and reportedly in early remission. A September 2015 VA examination report completed by the December 2011 VA examiner reflects diagnoses of antisocial personality disorder, unspecified personality disorder, and severe alcohol use disorder in reported sustained remission. The examiner noted that while the Veteran was previously diagnosed with PTSD by the August 2010 VA examiner, the August 2010 VA examiner did not appear to have access to the Veteran's complete electronic record and that the diagnosis of PTSD was made in error. The September 2015 VA examiner reiterated previous findings regarding what symptoms were attributable to each diagnosis and that the Veteran's personality disorders resulted in total occupational and social impairment. Upon examination, the Veteran was open, cooperative, and engaged with appropriate eye contact. Grooming and hygiene were average, he was casually dressed, and clean shaven. He was oriented and displayed no gross cognitive impairments. Mood was neutral and congruent with affect. Speech was normal in rate and pitch but tangential and difficult to follow. The Veteran denied obsessive thoughts, compulsive behaviors, suicidal or homicidal ideation, and hallucinations or delusions, and although his thoughts were frequently loose in their association, there was no evidence of a thought disorder. However, he was repetitive, tangential, and difficult to redirect at times. VA treatment records dated in July 2016 through February 2017 VA reflect that the Veteran's son was living with him and prepared his meals. The Veteran variously denied or endorsed transient depressed mood, dysphoria, anhedonia, and low energy, and sleep ranged from a few hours each night due to pain to a full night. He presented as fairly to appropriately groomed but somewhat disheveled. He was alert and oriented, his attitude ranged from hurried to calm and cooperative, his eye contact ranged from appropriate with periods of avoidance to frequent and sustained, and his speech was normal. The Veteran's mood appeared under control but affect ranged from dysphoric to euthymic. Memory was grossly intact, thought content ranged from ruminative to normal, thought processes ranged from circumstantial to coherent, and he denied suicidal and homicidal ideation and hallucinations. Judgment and insight ranged from fair to good. VA treatment records dated in November 2017 through April 2019 reflect the Veteran reported his appetite and sleep were okay, but he still had nightmares. He reported that he lived alone, had almost no friends, and did not like to be around others. He reported he was in contact with his sons but had recently had a dispute with his neighbors. Upon examination, the Veteran presented in casual and appropriate attire, he was alert and oriented, he was cooperative, and he maintained good eye contact. Speech was clear and thought content was without psychosis, but the Veteran's speech and thought process was described as verbose, tangential, and rambling, and required redirection. Mood ranged from mildly anxious to euthymic, affect ranged from anxious to bland to congruent. The Veteran's recent and remote memory were intact. Judgment and insight were fair. The Veteran denied suicidal and homicidal ideation. Treatment records reflect that in June 2019, the Veteran fell from a ladder and received a concussion. Due to his confusion, a psychiatric consultation was placed. A June 2019 VA psychiatric evaluation revealed normal motor activity and logical thoughts that were generally goal directed, but he displayed peculiar to circumstantial thought content. Speech was clear, mood was neutral with normal affect, he was cooperative, and without hallucinations. However, he displayed impulsive judgment and defective recent and remote memory. The clinician noted that the Veteran was initially described as circumstantial in July 2016 and had been described as such since, along with rambling and that he had difficulty focusing. The clinician concluded that there was likely no recent acute change in mental status related to the fall and concussion. However, there did appear to be a gradual decline in neurocognitive functioning, which the clinician believed to be perhaps related to the Veteran's prior history of heavy alcohol use. VA mental health treatment records dated in July and October 2019 reflect the Veteran presented as alert and oriented, cooperative, and with good eye contact. His dress ranged from disheveled to appropriate. Speech ranged from normal and clear to circumstantial, and he became difficult to follow. Mood ranged from mildly dysphoric to neutral, and affect ranged from sad to full and congruent. His recent and remote memory were intact. His concentration was fair and thought processes were logical and linear with normal content. The Veteran denied suicidal and homicidal ideation. Judgement ranged from fair to appropriate, and insight ranged from limited to fair. A January 2020 VA examination report reflects a history of PTSD with current diagnoses of unspecified personality disorder and unspecified depressive disorder with anxious distress. The examiner indicated that the Veteran did not meet the diagnostic criteria for a neurocognitive disorder, psychotic disorder, or PTSD, and that the previous diagnosis of PTSD appeared to be based on the Veteran's self-reported history. Additionally, the Veteran no longer met the criteria for a separate anxiety condition and his symptoms were incorporated into his depression diagnosis. The examiner indicated that it was possible to differentiate what symptoms were attributed to each diagnosis. Specifically, his personality disorder caused an enduring pattern of maladaptive behaviors reflected cognitively, effectively, interpersonally and through lack of impulse control and an extensive history of rule-violating behaviors, and his depression caused depressed mood, sadness, sleep disturbances, concentration problems, feelings of worthlessness, increased irritability, feeling tense, and fears of something bad happening. The examiner indicated that the symptoms of his personality disorder led to the development of his depression symptoms. Upon examination, the Veteran appeared casually dressed and groomed. He was alert and oriented, cooperative, and engaged. His speech was variable in rate, volume, and intensity. His thinking seemed tangential and disorganized at times though he was generally able to follow the interview. Mood was euthymic and affect was broad. The Veteran expressed clear future orientation and denied having thoughts of wanting to harm himself or others. After examining the Veteran and reviewing the claims file, the examiner found symptoms of depressed mood, anxiety, chronic sleep impairment, circumstantial, circumlocutory or stereotyped speech, speech intermittently illogical, obscure, or irrelevant, impaired judgment, disturbances of motivation and mood, difficulty adapting to stressful circumstances, including work or a work like setting, and an inability to establish and maintain effective relationships resulting in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, with 50 percent due to his personality disorder and 50 percent due to his depression. VA mental health treatment records dated in January 2020 through January 2021 reflect the Veteran reported that he continued to live independently, had a good appetite, cooked his own meals, and his sleep was okay, but that things would get mixed up in his head and he was forgetful. Upon examination, he appeared alert and oriented, adequately groomed, appropriately dressed, and had good eye contact. However, he continued to display disorganized thinking, had a difficult time focusing, and sometimes rambled and repeated himself. Speech ranged from limited to normal and he was without abnormal motor movements. Recent memory was intact but remote memory was impaired. Mood ranged from depressed to neutral, but affect was flat. He denied auditory or visual hallucinations and suicidal ideation. Insight and judgment were limited. A May 2021 VA examination report reflects diagnoses of schizoaffective disorder, depressive type; alcohol use disorder, severe, in long-term remission; and unspecified personality disorder. The examiner indicated that it was not possible to differentiate which symptoms were attributable to each diagnosis without speculation due to symptom overlap. Upon examination, the Veteran was described as odd, with hair askew, long, and unkempt. Eye contact was poor, and the Veteran was noted to be disturbed, distracted, and barely able to hold a coherent conversation or follow the theme or content of conversation. He was childlike and repeated himself several times while laughing hysterically. He demonstrated poor reality testing and cognitive impairment was evident. Affect was not appropriate to mood, content, situation, or circumstance. He speech rate slowed, then became animated. He denied suicidal ideation or intent, but the examiner indicated he was clearly delusional or psychotic. The examiner found symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, impairment of short and long-term memory, flattened affect, circumstantial, circumlocutory or stereotyped speech, speech intermittently illogical, obscure, or irrelevant, difficulty in understanding complex commands, impaired judgment, gross impairment in thought processes or communication, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, inability to establish and maintain effective relationships, impaired impulse control, such as unprovoked irritability with periods of violence, persistent delusions or hallucinations, grossly inappropriate behavior, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, resulting in total occupational and social impairment. The May 2021 VA examiner explained that the Veteran had a long history of alcoholism which may have contributed to mood dysregulation, memory impairment, and impaired thinking and behavior. His diagnoses of major depressive disorder with psychotic features and unspecified personality disorder resulted in very poor functioning overall and the examiner indicated that the Veteran likely coped by using alcohol and drinking to abuse for many years, although the Veteran was now in long-term sobriety. The examiner indicated that the Veteran had a life-long struggle with severe mental illness beginning in service, likely first expressed as a response to extraordinary stress related to the demand of training and service with poor adjustment to service. The examiner discussed a 1981 psychiatric evaluation in which the Veteran's affect was appropriate to mood but not appropriate to situation or circumstance, his thought processes and content showed loosening of association and some idiosyncratic association, conflicted ideation, suggestions of delusional ideals, and immature and impaired social judgment, and indicated that upon current examination and review of the Veteran's treatment records, the Veteran had not changed much since that time. The examiner explained that the military triggered a psychotic reaction and that the Veteran had been struggling with major depressive disorder with psychotic features and unspecified personality disorder for many years, all of which contributed to diminished quality of life, poor work performance, and difficulty in relationships. The examiner further explained that the Veteran had demonstrated mood instability, depression, anxiety, and delusional and paranoid behavior beginning in service and continuing since service. The examiner indicated that due to his psychosis and inappropriate behavior and mood, the Veteran would not be able to work in an environment where there was any stress, he would not get along with employers or employees, would not be able to learn new skills or implement tasks in a timely manner, would not be able to use computers, drive vehicles, or operate machinery due to his psychotic behavior and medication. He would be at risk of becoming dangerous towards others or having accidents that would put the company at risk. Upon review of the evidence of record, the Board finds that for the entire appeal period, the evidence is at least evenly balanced as to whether the symptoms and impairment caused by the Veteran's service-connected psychiatric disability more nearly approximates total occupational and social impairment. As indicated by the May 2021 VA examiner, the Veteran's schizoaffective disorder, depressive type, with alcohol use disorder, and unspecified personality disorder have resulted in mood instability, depression, anxiety, and delusional and paranoid behavior since service. The examiner further indicated that the severity of his psychiatric disorder had likely not changed since a 1981 psychiatric evaluation. The Board also finds it persuasive that the December 2011/September 2015 VA examiner also indicated that the Veteran's personality disorder resulted in total occupational and social impairment based on his inability to function within reasonable societal expectations. While the frequency and severity of the Veteran's service-connected psychiatric disability fluctuated and there are times which suggest that symptomatology associated with psychiatric disability may not have risen to the level contemplated by a 100 percent rating, resolving all doubt in the Veteran's favor, the 100 percent evaluation is appropriate. Thus, with reasonable doubt resolved in the Veteran's favor, the Board finds that for the entire appeal period, the Veteran's service-connected psychiatric disorder resulted in total occupational and social impairment. Accordingly, the Board finds an initial 100 percent rating is warranted for the Veteran's service-connected schizoaffective disorder, depressive type, with alcohol use disorder, and unspecified personality disorder. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s). 3. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. VA has a duty to maximize benefits which may include consideration of special monthly compensation (SMC) when reasonably raised. See Buie v. Shinseki, 24 Vet. App. 242 (2010). In light of the decision above, the issue of entitlement to SMC pursuant to 38 U.S.C. § 1114(s) may be reasonably inferred by the record. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008); Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). Under 38 U.S.C. § 1114(s), SMC is payable at the housebound rate if a veteran has a single service-connected disability rated as 100 percent and either of the following are met: (1) there is additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) he or she is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s). The Board's grant of an initial 100 percent evaluation for the Veteran's service-connected psychiatric disability from May 6, 2010 meets the criteria for a single service-connected disability rated as totally disabling for § 1114(s) purposes. See Bradley, 22 Vet. App. at 293-94. In addition, the Veteran is rated at 40 percent for a lumbar spine disability from January 11, 2011, and at 20 percent from February 11, 2021; left knee arthroplasty at 10 percent from January 11, 2011, 100 percent from February 14, 2018, 30 percent from April 1, 2019, and 60 percent from February 11, 2021; right knee meniscal tear at 30 percent from January 11, 2011; right knee instability at 10 percent from January 11, 2011; left knee meniscal tear at 20 percent from January 11, 2011 to February 14, 2018; tinnitus at 10 percent from November 15, 2006; fracture residuals of the third digit of the right foot as noncompensable from February 3, 1981; radiculopathy of the left lower extremity at 10 percent from January 11, 2021, and as noncompensable from February 11, 2021; radiculopathy of the right lower extremity at 10 percent from January 11, 2021, and as noncompensable from February 11, 2021; and scars associated with left knee arthroplasty as noncompensable from February 14, 2018. The Veteran is already in receipt of SMC pursuant to 38 U.S.C. § 1114(s) from February 14, 2018 to April 1, 2019 for his left knee arthroplasty rated at 100 percent and additional disabilities independently ratable at 60 percent or more; and from May 7, 2021 for his service-connected psychiatric disability rated at 100 percent and additional disability (left knee) independently ratable at 60 percent or more. However, with the Board's grant of an initial 100 percent evaluation for the Veteran's service-connected psychiatric disability, the Veteran is now rated at 100 percent for his service-connected psychiatric disability from May 6, 2010, with additional disabilities independently ratable at 60 percent or more from January 11, 2011. As the Veteran has a single service-connected disability rated as totally disabling for § 1114(s) purposes and an additional, service-connected disabilities that are independently ratable at 60 percent or more from January 11, 2011, the criteria for entitlement to SMC under 38 U.S.C.§ 1114(s) from January 11, 2011 are met. As no additional disability compensation may be paid when a total schedular disability rating is already in effect, and the Board is granting SMC under 38 U.S.C. § 1114(s), entitlement to a TDIU from January 11, 2011 is rendered moot. From May 5, 2010 to January 10, 2011, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of a TDIU may form the basis for an award of SMC. Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). Thus, the question before the Board is whether TDIU is warranted prior to January 11, 2011, for purposes of SMC. In August 2016, the Board found that entitlement to a TDIU had been raised as part of the Veteran's psychiatric disability increased rating claim pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Specifically, in the Veteran's April 2012 VA Form 9 (Appeal to the Board of Veterans' Appeals), the Veteran stated that his psychiatric disability had become so severe he was unable to work. The Board remanded the claim and in September 2018, June 2019, and January 2020 letters, VA requested the Veteran complete and return VA Form 21-8940 (Veterans Application for Increased Compensation Based on Unemployability). To date, no response has been received from the Veteran. A TDIU may be assigned "where the schedular rating is less than total" and the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). The Veteran's primary contention during the claim period has been that he is unable to work due to his service-connected psychiatric disorder, and the 100 percent evaluation which is being granted throughout the entire claim period specifically contemplates total unemployability (i.e., total occupational impairment) due to his psychiatric disorder. Thus, the Board must look to the Veteran's other service-connected disabilities to determine whether TDIU is warranted. From May 6, 2010 to January 10, 2011, aside from his psychiatric disorder, the Veteran was service-connected for tinnitus, rated 10 percent disabling, and residuals of a third digit fracture of the right foot, rated as noncompensable. The Veteran has not contended, and the evidence does not otherwise show, that either tinnitus or residuals of a third digit fracture of the right foot, alone or in combination, are of such a severity so as to preclude all substantially gainful employment. The facts presented in this case are distinguishable from those in Bradley v. Peake, 22 Vet. App. 280 (2008), because in this case the Veteran does not contend, and the evidence does not show, that any service-connected disability or disabilities other than the disability for which a 100 percent rating is being assigned render the Veteran unemployable. Under the facts presented in Bradley, there was no "duplicate counting of disabilities." Bradley, 22 Vet. App. at 293. Here, if the Veteran were to be awarded a TDIU ("total" rating) based on his service-connected psychiatric disability rendering him unemployable for any time during the rating period, it would impermissibly result in the same disability being "counted twice" in the assignment of a total rating, as it would be rating the "total occupational impairment" twice. See generally, 38 C.F.R. § 4.14. Without any argument asserting unemployability due to another service-connected disability, there is no question of law or fact to decide regarding the TDIU issue. Thus, the Board finds that the issue of entitlement to a TDIU prior to January 11, 2011, to include for purposes of SMC, must be dismissed as moot. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 4.14, 4.16. REASONS FOR REMAND 1. Entitlement to service connection for an eye condition is remanded. 2. Entitlement to compensation under 38 U.S.C. § 1151 for vision loss is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for an eye condition or compensation under 38 U.S.C. § 1151 for vision loss at this time. The Veteran contends that he has an eye condition due to exposure to chemical fumes during service. Alternatively, he argues that he suffered vision loss after a VA surgery. In August 2016, the Board remanded the matters so that a VA examination and medical opinion could be obtained. While a VA examination and medical opinion was obtained in January 2020, and the examiner opined that it was less likely than not that the Veteran's vision disability, diagnosed by the examiner as dry macular degeneration of the right eye and age-related cataracts of the eyes bilaterally, was incurred in or caused by service or that any additional disability involving the Veteran's vision was caused by the April 2010 or April 2011 VA surgeries, the examiner indicated that there were several references to eye examinations in the record, but that few were scanned into the record and the examiner did not have access Vista Imaging. Thus, in April 2020, the Board remanded the matter so that records located in Vista Imaging could be associated with the record and an addendum medical opinion obtained. VA obtained a new VA examination and medical opinion in December 2020. After examining the Veteran and reviewing the medical records, the examiner provided a diagnosis of mild cataracts of the eyes bilaterally. The examiner indicated that the Veteran did not have glaucoma or tunnel vision and opined that his cataracts were due to aging rather than his time in service, including any exposure to fuel and fumes. The examiner indicated that there were no additional visual disabilities caused by the April 2010 or April 2011 surgeries. In March 2021, VA associated the outstanding medical records located in Vista Imaging with the Veteran's claims file, including numerous records relating to the Veteran's vision and vision examinations. As the records located in Vista Imaging were not obtained and associated with the record until after the December 2020 VA examination and medical opinion, it is not clear that the December 2020 examiner was able to consider these records, dated from 2005 to 2019 and showing diagnoses of macular degeneration, drusen, suspected glaucoma, cataracts, loss of and/or poor visual field, and vitreous degeneration, when finding that the Veteran only had cataracts that were unrelated to service and no additional disabilities after his VA surgeries. Thus, the Board finds that a remand is warranted for an addendum medical opinion. The matters are REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records from January 2021 to present. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's claimed eye/vision condition. The examiner must review the claims file. An in-person examination is not necessary unless deemed so by the examiner. The examiner should identify any diagnosed eye/vision condition during the appeal period, to include macular degeneration, drusen, suspected glaucoma, cataracts, loss of and/or poor visual field, and vitreous degeneration. For each identified eye/vision condition, the examiner is asked to provide a response to the following: a. Is the eye/vision condition at least as likely as not related to service, including the Veteran's lay statements regarding exposure to fuel and fumes? b. Is it at least as likely as not that any additional disability involving the Veteran's eyes/vision was caused by the April 2010 or April 2011 surgeries performed at the Grand Junction VAMC? c. If a relationship between the eye/vision condition and the April 2010 or April 2011 surgeries is shown, the examiner must opine as to whether it is at least as likely as not that the additional disability was the result of (1) carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA, or (2) an even not reasonably foreseeable. An event not reasonably foreseeable is one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. Provide a rationale to support the opinion(s). 3. After completing the above, and any other development as may be indicated, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.