Citation Nr: 0027162 Decision Date: 10/13/00 Archive Date: 10/19/00 DOCKET NO. 93-20 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. The veteran's dissatisfaction with the initial 30 percent disability evaluation assigned following a grant of service connection for post-traumatic stress disorder. 2. Whether the veteran may be considered competent for Department of Veterans Affairs benefit purposes. WITNESSES AT HEARINGS ON APPEAL Veteran and parents ATTORNEY FOR THE BOARD Martin F. Dunne, Counsel INTRODUCTION The veteran served on active duty from February 1974 to January 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1992 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, which implemented the Board's May 1992 decision granting service connection for post-traumatic stress disorder (PTSD). In that decision, the RO assigned the disability a 30 percent evaluation, effective from July 1990, the date of receipt of the veteran's claim. The veteran appealed the 30 percent disability evaluation. He also appealed a September 1996 rating decision by the RO, which determined that he was not competent for VA purposes to handle disbursement of funds. The veteran and his parents testified at a personal hearing before a hearing officer, which was held in June 1993, and before the undersigned Veterans Law Judge in August 1993, which also was held at the RO. During the latter hearing, the veteran indicated his desire to revoke all powers of attorney and he submitted additional evidence, along with a signed waiver of RO jurisdiction of that evidence. See 38 C.F.R. § 20.1304 (1999). The Board remanded the case in January 1996 for further development and for clarification of the status of any representation of the veteran. In March 1996, the veteran submitted a written statement in which he stated that he revoked his power of attorney with his representative. See 38 C.F.R. § 20.607 (1999). Since the record does not contain any subsequent submission by the veteran delegating another representative, he remains unrepresented in this case. During the appeal process, the case again was remanded in November 1997 and September 1999 for further development. Following completion of the latest remand directives, the case has been returned to the Board for appellate review. The issues currently before the Board are the veteran's dissatisfaction with the initial rating assigned at the time of the grant of PTSD, which the Board has recharacterized as involving the propriety of the assignment of the initial rating, see Fenderson v. West, 12 Vet. App. 119 (1999), and whether the veteran may be considered competent for VA benefit purposes. The Board notes that in August 1999 the veteran requested to reopen his claim for an effective date earlier than July 1990 for the grant of service connection for PTSD and for entitlement to a total disability rating based on individual unemployability. As those issues have not been adjudicated by the RO, they are not before the Board. FINDINGS OF FACT 1. All relevant evidence necessary for the equitable determination of the veteran's appeal has been obtained by the RO. 2. The veteran has symptoms of avoidance, depressed mood, anxiety, suspiciousness, irritability and chronic sleep impairment associated with his service-connected psychiatric disability. 3. Neither the former criteria for evaluating psychiatric disabilities, in effect when the veteran filed his claim expressing his dissatisfaction with the initial disability evaluation assigned his PTSD, nor the revised criteria, which became effective November 7, 1996, are clearly more favorable to his claim. 4. The veteran's PTSD has been shown to result in no more than definite occupational and social impairment; or (since November 7, 1996) occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss. 5. Medical opinion from examining psychiatrists is that the veteran lacks the capacity to manage his own affairs, including disbursement of funds without limitation. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.130, 4.132 Diagnostic Code 9411 (1996 & 1999). 2. The veteran is not competent for VA purposes to manage his own affairs, including the disbursement of funds without limitation. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.353 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background At the time of examination conducted in December 1973, shortly before he entered service, the veteran, over his signature, denied having any psychiatric complaints, denied having made a suicide attempt and denied having had any treatment for a mental condition. Service medical records show that he was AWOL for a time in 1975 allegedly because he felt that he was being harassed by his NCOIC and CO. He was taken to the Correctional Custody Facility where he reportedly was harassed and beaten up. He escaped from that facility, got in touch with his parents, and was taken to the emergency room at Madigan Army Medical Center. On physical examination, bruises were noted. He stated that he would be harassed and injured again if he were returned to the Correctional Custody Facility. His behavior on the ward was appropriate and without evidence of major psychiatric disabilities. Psychiatric evaluation during this period, in September 1975, was conducted, at the conclusion of which it was concluded that, while there was no evidence of mental disease or defect, it was not believed that the veteran's condition was amenable to any form of punishment, retraining or other rehabilitation within the military setting. The veteran was felt to represent more of a liability than asset to the military. The veteran's unit commander stated in December 1975 that during his service in the unit, the veteran's behavior had been characterized by a "total unwillingness to perform in an acceptable manner," by refusing to adhere to military standards of dress, courtesy, and discipline. Despite repeated attempts to counsel him, the veteran had steadfastly refused to conform, maintaining an attitude of belligerence. He was subsequently discharged from military service in lieu of court-martial. His certificate of discharge was upgraded to Under Honorable Conditions in 1977. The veteran underwent a Vet Center intake medical evaluation in July 1990 and was reported as presenting a bizarre, incredibly involved story about suffering from extreme mistreatment at the hands of the military. He was also the subject of a VA social and industrial history for PTSD in August 1990. The diagnostic impressions were to rule out PTSD, chronic alcohol abuse, and to rule out other psychiatric disorders, including personality disorder. Essentially, the veteran reported having been jailed in service where he was severely beaten and tortured, and of being stripped, whipped, and bashed with a toilet bowl brush until his pores bled. He further claimed that he had held forty to forty-five different jobs subsequent to his military separation. On VA psychiatric examination in August 1990, the examiner reported that it was difficult to decide whether the veteran suffered from PTSD; however, given the veteran's reported experiences in service, a review of the record and examination of the veteran, the examiner's impression was that the veteran suffered from PTSD, but that his overwhelming problem was his personality disorder which pre- existed his military service, but was aggravated by the episode at the Correctional Custody Facility. It was noted by the examiner that the veteran did not function very well in high school, that he had had difficulty with social relationships, and that he had performed poorly in school due to a learning disability. The examiner further noted that the veteran's alcohol abuse seemed primarily related to his personality disorder, which also was aggravated by the events at the Correctional Custody Facility. Inasmuch as there was a question as to whether the veteran suffered from PTSD as a result of the reported traumatic event in service, a medical expert opinion was requested by the Board. In February 1992, the Director of the Mental Health and Behavioral Sciences Service of a VA Medical Center reported, after reviewing the entire evidence of record, that the record supported the diagnosis of PTSD. In May 1992, the Board granted service connection for PTSD. The veteran underwent VA social and industrial survey for PTSD, as well as VA psychiatric examination, in June 1992 during which it was reported that he was adopted by his parents when he was an infant; he had a learning disorder while in school; he abused alcohol considerably from 1975 to 1978, and he was still drinking because it calms him; and he lived alone in his own home, which was gifted to him by his parents. The veteran was accompanied to the examination by his parents, who insisted on remaining throughout the interview. The veteran reported experiencing flashbacks, nightmares, hypervigilance, problems with memory and concentration, and that he does not engage in significant social relationships because he does not feel fit. On mental status examination, his affect was excellent and showed no signs of a schizoid type. The veteran denied using psychiatric medication and did report treatment at Seattle Mental Health Institute. The diagnoses were PTSD, somewhat atypical in nature; mixed personality disorder, covering the possibilities from compulsive to paranoid to aggressive; and a learning disability, type uncertain. By rating decision of October 1992, the RO implemented the Board's May 1992 decision granting the veteran entitlement to service connection for PTSD, and the RO made the award effective from July 1990, the date of receipt of the veteran's claim. The disability was assigned a 30 percent evaluation, which also was made effective from July 1990, the date of the reopened claim. In June 1993 the veteran along with his parents appeared at a hearing before the RO, at which time he asserted that he was seeking a permanent 100 percent rating. He testified that he was in receipt of Social Security disability benefits, that his illness was longstanding, and that he had been told by a private medical care provider that he was totally disabled. He reported that he had terminated his PTSD treatment because such aggravated his stress. In August 1993 the veteran along with his parents appeared at Board hearing before the undersigned. The veteran compared his situation that of other veterans who he stated were evaluated as 100 percent disabled. He pointed out that he hadn't worked since 1987 when he was a basic laborer. He noted that he had not completed high school because of a learning disorder. He was receiving no medication, nor was he involved in counseling. He claimed that he spent his days working on his claim for compensation. He was able to do his own shopping and drive, but relied on his parents for help with paying the bills. He complained of nightmares, flashbacks, depression and anxiety. The veteran's mother indicated that the veteran had no social life, was totally absorbed by his claim, and found his only "release" to be alcohol. Along with a February 1994 letter listing many of the veteran's complaints against the government, including his claims for tort relief and for violations of his constitutional rights, were excerpts from publications from various government and military offices, and the American Civil Liberties Union. None of the published material pertain specifically to the veteran or his claim. Received in connection with the Board's remand of this case, in order to develop the record, were reports from The Children's Orthopedic Hospital, covering the period of the veteran's ages of nine to seventeen, reflect treatment for passive-aggressive personality disorder. In these records the veteran was described as showing an emotional reaction to his mother's over-preoccupation with him, with numerous obsessive thoughts of anger and hurting. He was assessed as having a significant and "very serious" personality disturbance. The reports from University Hospital from September 1970 to April 1971 reflect the veteran's participation in sessions for an adjustment reaction of adolescence with a strong situational component and learning problem with some psychological component of etiological significance. The February 1987 medical report from Good Samaritan Neuropsychological Services shows that the veteran underwent evaluation testing for a learning disability. The test results indicated that the veteran was severely handicapped by his developmental deficits and qualified him for consideration as a learning disabled person. The Department of Social and Health Services reports for March 1987 to January 1988 show that the veteran had a history of learning disabilities and personality disorder. Also received were documents showing that in 1988, the veteran was awarded Social Security Administration benefits, which were continued in 1991. The basis for the award, and continuation thereof, was a continuing disability due to a learning disability, personality disorder, PTSD and alcohol abuse. Statements from a private counselor, S. Watt, M.S.W., dated in July 1990 and November 1991, show that, based on the veteran's own presentation and materials he presented, the veteran meets the criteria for a diagnosis of PTSD. The trauma in question was his incarceration and associated treatment, or handling, in a Correctional Custody Facility while he was on active duty. In the November 1991 statement, the counselor noted that he had examined the veteran and found him oriented, calm and cooperative. He had found no evidence of hallucinations and, although some paranoid ideation was seen, it was not of a psychotic or delusional nature. The veteran exhibited a distrust of large institutions. The counselor noted that the veteran's daily activities, social functioning and living situation were all strongly negatively impacted by his illness. The counselor found that the veteran exhibited intense need for control, a fearfulness in regard to new or unexpected situations, and an inability to make meaningful contact with appropriate peers. Further, the examiner found that the veteran's ability to concentrate and carry through on routine tasks was severely compromised as a result of his obsessive/compulsive features and his need for a perfect product. He also experienced almost overwhelming stress and anxiety when faced with ordinary situations that to which most people give little or no thought. Records from Seattle Mental Health Institute in the early 1990s show a history of alcohol use dating back to age 13 and extensive physical abuse "as he grew up." The treating physician noted that review of the extensive clinical record developed when the veteran was age 9 through 16 showed brain damage, a learning disability, adjustment disorder of adolescence, and passive-aggressive personality disorder. The veteran's parents were described as being very rigid. It was concluded by the examiner that the veteran could not work, and that he was totally disabled. The veteran was afforded VA social and industrial survey, conducted by a social worker, in March 1996. An extensive report was prepared. It was noted that the veteran had discontinued any contacts with VA facilities, stating that treatment was not effective and that he didn't expect to get any better. It was noted in the record, and the veteran confirmed, that he had made 2 suicide attempts, one before service in 1973 and the other in 1976. The pre-service attempt resulted from his feelings of depression and poor school performance, while the latter attempt was in response to the distressing experiences the veteran had in service. His pre-service psychological problems and abuse of alcohol were noted. On examination, the veteran was described as calm and rationale in manner. He had not worked since 1987, spending his time working on a lawsuit against VA and pursuing his claim. Otherwise he spent his time visiting his parents, caring for his pets, or visiting a nearby park. The social worker noted that it was questionable whether the veteran could work, in view of his obsessive focus on his legal suit, although he was described as appearing well organized and of more than adequate intelligence. However the veteran was felt to be able to perform at most types of employment if he was emotionally and psychologically able to do so. He was reported to be taking no medication, under no current mental health care, and having no plans to do seek such care. In March 1996, the veteran underwent VA medical examination by a board of two VA psychiatrists, A. W., M.D., and P. P., M.D., both of whom also reviewed the veteran's records. At the veteran's and parents' insistence, the veteran was evaluated in the presence of his parents. His history was presented in an extremely rambling and circumstantial manner, making the interview difficult. By history, the examination report notes that the veteran was living alone in a home furnished him by his parents and that he was receiving some financial support from them, in addition to his VA and Social Security benefits. He reported that he had run up credit card debts of approximately $50,000. He led an isolated life. He related that he gets "totally blitzed" up to eight times a month on alcohol and, at other times, he maintains periods of sobriety, primarily so that he can have a clear head to work on the intricacies of his case, sometimes for twenty-four hours straight. He maintained that he had never been on medication for a psychological problem nor had he ever been a psychiatric inpatient, except for a brief period at Madigan Hospital while on active duty. The veteran denied any meaningful or long-term relationships and he had never married. He related that he experiences intrusive thoughts and, at times, dreams about his reported trauma in the service. During his many jobs as a security guard, he stated that he sometimes had "flashed back" to the time he had been beaten by military policemen. The VA psychiatrists noted that the veteran's range of affect seemed to be restricted to anger, irritability and self- confessed "paranoid feelings" about others. The effect of his symptoms and characteristics on employment seemed to have been significant, although the veteran attributed most of his employment difficulties to the nature of his discharge rather than to irritability or other interpersonal problems. On mental status evaluation, he was cooperative and his memory was acute with no evidence of amnesia or other memory difficulty. He was well oriented. His fixation on his self- reported abuse in the military approached the paranoid in degree. There was no loosening of associations or inappropriate affect, hallucinations, or other stigmata of a primary thought disorder. He was almost totally insightless and had no plan or perceived need for mental health treatment. The examiners noted that the veteran's financial management skills, corroborated by his own testimony and by his parents, were extremely poor. The psychiatrists offered that the veteran's behavior pattern represented a mixture of symptoms of PTSD and personality disorder with multiple components, including a paranoid one. The examiners found that an exact apportionment between the PTSD and personality factors of the veteran's impairment was difficult, but it appeared to them that these categories have approximately equal weight in this case. The examiners further stated that, in the veteran's continuing frame of mind and with his obsessive fixation on his case, it did not appear likely that he could adjust at all to the demands of the workplace. The diagnoses were PTSD, chronic, moderate in degree; alcohol abuse, continuous; and personality disorder NOS (not otherwise specified) with paranoid features. The examiners assigned a GAF (Global Assessment of Functioning) score of 40 to his overall disability noting that the score reflected a major impairment in work, family relations, thinking, and judgment. Further, the examiners recommended that the veteran be rated incompetent for VA purposes in view of his manifest mismanagement of his financial affairs. The veteran underwent VA psychological testing by D. T., Ph.D., in April 1996. His report notes that the results of the evaluation suggested a complicated diagnostic picture compounded by clinical levels of depression and anxiety, idiosyncratic and unusual thinking, avoidance behavior, alcohol abuse, and predominant paranoid disposition. The PTSD evaluation results indicated that the veteran had been negatively affected and distressed by his military experiences. His identified cognitive deficits appeared to have further complicated and characterized his social adjustment problems throughout his life, lending themselves to an ingrained pattern of alienation and perceived persecution. The report further notes that the veteran's general and delayed memory, particularly as it pertained to verbal material, as well as his attention/concentration abilities, were found to be below what was expected, given the veteran's age and educational background, yet may reflect a static level of functioning, given his account of his early life history. The report further notes that the veteran's memory and concentration problems may be further compromised by the significant levels of depression reported, as well as by a substantial history of alcohol abuse, beginning at age 14. During the evaluation, the veteran declined referral assistance stating that it would distract from his current need to devote all his time and energy focusing on the preparation of his case. In June 1996 it was proposed to declare the veteran incompetent to handle VA funds because of PTSD, alcohol abuse and personality disorder. A finding of incompetency was made in September 1996 and the veteran was advised. A VA outpatient treatment report of June 1997 notes the veteran was complaining of flashbacks, both auditory and visual, and that he was disturbed by his own actions, which he was reluctant to discuss. On medical consultation, he refused laboratory work-up and stated he was having second thoughts about seeing a psychiatrist. If he was unwilling to receive care at the clinic, he was advised to seek PTSD and substance abuse support groups. A. W., M.D., who was one of the two VA physicians who had examined the veteran in March 1996, again examined him in January 1998. Since the veteran had been examined by this physician previously, the veteran was offered an opportunity to be examined by a different examiner, but he indicated he wished to "get it all over with" today and not have to return for further appointments. The examination report notes that, although the Social Security Administration decision granting the veteran benefits was available for review by the examiner, the medical examination reports supporting the decision were not available. The examiner noted that the veteran's psychiatric history was almost word for word that reported by the previous examination in 1996. Since that time, the veteran had had only one brief occasion seeking VA medical treatment and denied seeking care anywhere else. He was taking no psychotropic medication and was receiving no counseling. He indicated he was still using alcohol in a binge pattern on weekends. The veteran related symptoms of PTSD, such as sleep disturbance, maintaining a considerable degree of estrangement from others and social isolation, although he emerged from this at least weekly to drink with others in a public setting. The report notes that the veteran evidenced a high degree of distrust of others; that he had problems with anger; that he had had no significant male-female relationships for years; and had an uneasy dependency relationship with his parents. He had no difficulty in concentrating. He reported some degree of hypervigilance, but he did not mention exaggerated startle responses. It was stated that the veteran had "maxed out" approximately 13 credit cards and had no idea how much money he owed. In addition, he owed his parents $48,000. He explained that he was reluctant to file for bankruptcy because he felt that to do so would jeopardize his credit rating; he did agree with the examiner that his financial situation was poor. The VA examiner noted that the veteran continued to manifest many symptoms of personality disorder, including poor interpersonal functioning, a pervasive distrust and suspiciousness of others, and preoccupation with doubts about the trustworthiness of others. The examiner further indicated that the veteran evidenced several psychiatric disorders, including just enough criteria in the required categories to make a diagnosis of PTSD possible, although in the veteran's overall presentation, the physician found issues that were much more predominant, and those appeared to be in the realm of his personality disorder. Further, the physician noted that the veteran appeared to have given up any effort to obtain gainful employment and, since he had not attempted such for may years, the examiner noted that it was difficult to assess how the veteran might do in establishing or maintaining effective work or social relationships but, from his overall lifestyle, it seemed more likely than not that the veteran would have significant difficulty in view of his intense focus inward upon himself, his sense of entitlement, and his suspiciousness. The psychiatrist opined, based on review of the record and examination of the veteran, that the veteran's overall impairment, giving him the benefit of every doubt, is no more than half caused by PTSD and that the remainder of his difficulties must be attributed to his personality disorder. The diagnoses were PTSD, chronic, currently moderate; alcohol abuse, continuous; personality disorder NOS, with particular paranoid features; and a learning disorder, mild. The examiner assigned a GAF score of 40, based on the combination of PTSD and personality disorder. The physician noted that the veteran has a major impairment in family relations, work, judgment, and thinking. The physician further noted that if the veteran had no PTSD, his GAF score would still be in the serious level, with a projected score of 50 due to personality disorder; had he no personality disorder, the PTSD symptomatology shown might result in a GAF score of around 60. With respect to the competency determination, it was opined that the veteran's demonstrated incapacity [to handle his finances] was remarkable and constituted a burden to his parents and the business community. The veteran had little insight and no improvement in judgment. The psychiatrist recommended that the veteran be rated as incompetent for VA purposes, in the absence of evidence showing he had gained the mental capacity to contract or manage his own affairs, including disbursement of funds without limitation. The report of the veteran's August 1998 VA field examination and addendum report of October 1998 reflect that the field examiner had not previously met the veteran and that he had visited the veteran at his home unannounced. The reports note that the veteran presented well and his home was clean and orderly. To the examiner, the veteran seemed to be doing well; he was able to provide for his living needs; and he functioned independently in the community, with some help from his parents as a support system. In the opinion of the field examiner, the veteran was competent for VA purposes. In November 1998, the veteran again was examined by VA, P. P., M.D., one of the two psychiatrists who had examined the veteran in March 1996. The psychiatrist reviewed the records, including the above-mentioned field examiner's report and addendum, and noted that it appeared the field examiner did not have the benefit of having the recent psychiatric examination reports to review. The physician, based on review of the records and psychiatric evaluation, offered that it would be in the veteran's best interest for him to be declared incompetent for VA purposes, as evidenced by the veteran's gross difficulties managing financially and massive debt that he had accumulated. On that occasion, the veteran was described as being fully oriented, very emotionally detached, simplistic in his general attitude, and having poor eye contact. A. W., M.D., re-examined the veteran in June 2000, and reviewed the veteran's records, including his Social Security Administration records which were unavailable at the time of his last examination of the veteran. This VA physician noted that the current examination was remarkably similar to the veteran's previous examinations, with his overall lifestyle remaining much the same. The examiner also noted that the veteran was currently in a VA substance abuse program, which the veteran indicated was court-ordered as a result of a DWI arrest; that he remained in an uneasy dependent relationship with his parents; that he lived in a home they purchased for him; and that he now depended on them for transportation to his various appointments since he was not driving. Since the last examination, he had filed for bankruptcy protection from his many creditors. He was unable to estimate how much money he owed. During the examination, the veteran did not present noteworthy emphasis on symptoms of PTSD, although he did mention some in passing. He alluded to intrusive thoughts about his reported physical abuse while incarcerated during his military service and to some degree of sleep disturbance. He did not, however, avoid reminders of military service and, in fact, presented a remarkable physical appearance wearing some articles of military clothing with many military insignia on them, both on an inner shirt and on an outer jacket. He indicated a lack of an affectionate relationship with women and only an uneasy dependence on with his parents. His social life was quite restricted and he seemed to make or establish beneficial relationships only with great difficulty. He did not present himself as being an angry person, although he did indicate some irritability in certain directions. He remained distrustful, vigilant and had a high level of suspiciousness of others. The examiner noted that the veteran continued to show a remarkably immature approach to the management of everyday life and to his financial situation. The physician reported that the veteran was currently in bankruptcy proceedings, which seemed to be bringing some order out of what had been years of chaos. His judgment was remarkably impaired and focused only on claims activities. He showed a distinct lack of motivation to participate in broader activities of life or work and did not form effective work or social relationships. His suspiciousness was considered noteworthy, which the examiner noted could be related both to a personality difficulty and to PTSD. The physician reported that the veteran was on time for the examination; that he made good eye contact; and that he was generally affable. He appeared euthymic and very verbal. There was a highly histrionic and narcissistic quality to his presentation. His general attitude of irresponsibility and immaturity was striking. His speech tended to be very circumstantial, although he could be redirected. He was oriented to time, place, person, and purpose of the examination. He did not show gross memory defects. He showed no signs of psychotic process, such as hallucinations, delusions, or loosened associations, although his affect seemed quite sprightly and lively compared to his claimed grievances. His level of psychological insight was remarkably low, although he professed to be enjoying group therapy and he had even joined Alcoholics Anonymous on a voluntary basis. As for the veteran's money management situation, the psychiatrist noted that it did not appear to have varied much from previous descriptions, except that he was now undergoing bankruptcy proceedings. In the examiner's opinion, the veteran's presentation and lifestyle seemed little changed from when he had last examined the veteran in January 1998; it was also congruent with the earlier findings of a board of two psychiatrists and with a psychiatric examination report dated in November 1998. The examining psychiatrist added that a review of the Social Security Administration documents did not reveal information which would substantially require alteration of previous VA diagnoses; personality disorder played a prominent role and was indeed the basis of his original award, although PTSD was later noted on a review and, at times, substance abuse also was a factor. The examiner offered that the veteran's symptom picture has markedly impaired his reliability and flexibility so that a very considerable amount of industrial impairment was present. The examiner noted that there was some over-lap in symptomatology, but the veteran's impaired interpersonal relationships were noteworthy and typical of PTSD. His circumstantial speech was more a personality disorder symptom. Suspiciousness was a very typical variant of the irritability and distrust found in PTSD, as was chronic sleep impairment. His difficulties with judgment were a matter of personality difficulty and were not typical of PTSD. The examiner opined that, with the complexity and over- lapping of symptomatology, a 50-50 distribution of causation as between PTSD and personality disorder was justified. The examiner commented that several psychiatric examiners in the past had recommended that the veteran be rated as incompetent, although those opinions were based on the veteran's impaired judgment and financial management arising out of his personality disorder rather than from PTSD. Further, the examiner found the veteran was continuing in his lifestyle, but was now in bankruptcy proceedings, thereby punctuating the earlier observations by those examining psychiatrists concerning the veteran's financial capabilities. It still appeared to the psychiatrist that, because of the veteran's severe personality disorder, he lacked the capacity to manage his own affairs, including the disbursement of funds without limitation. The diagnoses were PTSD, chronic, moderate; alcohol abuse, in reported sustained remission in a treatment program; remote history of learning disability; and personality disorder, not otherwise specified, with components of histrionic, narcissistic, dependent, and borderline aspects. He assigned the veteran a GAF score of 40, reflecting his major impairment in family relations, work, judgment, and thinking. II. Analysis As a preliminary matter, the Board finds that the veteran's claims for higher evaluations for PTSD and whether he may be considered competent for VA purposes are well grounded within the meaning of 38 U.S.C.A. § 5107(a). See Caffrey v. Brown, 6 Vet. App. 337, 391 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Furthermore, the Board is satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required in order to comply with the duty to assist on this issue. Id. A. Higher Evaluations for PTSD Essentially, the veteran is asserting that his PTSD is more severely disabling that reflected in the 30 percent evaluation as assigned. He maintains that his disability is and has been such that a 100 percent evaluation is warranted. The VA utilizes a rating schedule as a guide in the evaluation of disabilities resulting from all types of diseases and injuries encountered as a result of or incident to military service. The disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1, Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. It is essential, both in the examination and in the evaluation of disability, that each disability be reviewed in relation to its history. See 38 C.F.R. § 4.41. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, as in the case at hand, where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson, 12 Vet. App. at 126. In this case, the RO has issued numerous rating decisions and supplemental statements of the case, each of which reflects consideration of additional evidence under the applicable rating criteria. Thus the RO effectively considered the appropriateness of its initial evaluation under the applicable rating criteria in conjunction with the submission of additional evidence at various times during the pendency of the appeal. The Board considers this to be tantamount to a determination of whether "staged rating" was appropriate and in compliance with the holding in Fenderson. In the veteran's case, his service-connected PTSD is evaluated under schedular criteria for evaluating psychiatric disabilities. By regulatory amendment effective November 7, 1996, substantive changes were made to that criteria, as set forth at 38 C.F.R. §§ 4.125-4.132. See 61 Fed. Reg. 52695- 52702 (1996). Where laws or regulations change after a claim has been filed or reopened, but before the administrative or judicial appeal process has been concluded, the version most favorable to the veteran applies, absent Congressional or Secretarial intent to the contrary. See Dudnick v. Brown, 10 Vet. App. 79 (1997); Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). In this regard, the General Counsel of VA has recently held that where a law or regulation changes during the pendency of a claim for an increased rating, the Board should first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C.A. § 5110(g) can be no earlier than the effective date of that change. The Board must apply only the earlier version of the regulation for the period prior to the effective date of the change. See VAOPGCPREC 3-2000 (2000). Here, neither the former nor the revised applicable schedular criteria are clearly more favorable to the veteran's claim. Inasmuch as the RO has appropriately considered the veteran's claim under the former and revised criteria, there is no prejudice to him in the Board doing likewise and applying the more favorable result, if any. See Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993). Prior to November 7, 1996, PTSD was evaluated using criteria from the general rating formula for psychoneurotic disorders. See 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). Under this formula, the current 30 percent evaluation was assigned for PTSD upon a showing of a definite impairment in the ability to establish or maintain effective and wholesome relationships with people; the psychoneurotic symptoms resulted in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite social impairment. See 38 C.F.R. § 4.132. The term "definite" was defined as "distinct, unambiguous, and moderately large in degree" and as representing a degree of social and industrial inadaptability that is "more than moderate but less than rather large." See O.G.C. Prec. 9-93, 59 Fed. Reg. 4752 (1994). See also Hood v. Brown, 4 Vet. App. 301 (1993). A 50 percent evaluation was assigned where an ability to establish or maintain effective or favorable relationships with people was shown to be considerably impaired, or by reason of psychoneurotic symptoms the reliability, flexibility, and efficiency levels so reduced as to result in considerable industrial impairment. See 38 C.F.R. § 4.132. A 70 percent evaluation was warranted where the veteran's ability to establish or maintain effective or favorable relationships with people was shown to be severely impaired, or by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels were so reduced as to result in severe industrial impairment. Id. To warrant a 100 percent evaluation, the attitudes of all contacts except the most intimate must have been so adversely affected as to result in virtual isolation in the community; or there must have been totally incapacitating symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior; or, as a result of the psychiatric disability, the individual must have been unable to obtain or retain employment. These criteria represent 3 independent bases for granting a 100 percent evaluation. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Under the revised criteria, now set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999), a 30 percent evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). See 38 C.F.R. § 4.130. A 50 percent evaluation 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. Id. Additionally, a 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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. Id. Finally, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Applying the relevant law and regulations to the facts in this case and following a careful review of the evidence, the Board finds that the record presents no basis for assigning a higher evaluation for PTSD under either the former or the revised applicable schedular criteria. During the course of this appeal, the veteran was afforded numerous pertinent VA examinations. The record also contains several VA outpatient treatment reports; private medical reports from various medical facilities; a copy of a decision awarding disability benefits from the Social Security Administration, including the records upon which that determination was based; written statements and personal testimony from the veteran and his parents; and VA field examination report. Essentially, the medical evidence presents a veteran who has, by competent medical opinion, both PTSD and personality disorder. He is service connected for PTSD; however, personality disorder is not a disease within the meaning of the applicable legislation. See 38 C.F.R. § 3.303. This case was remanded previously in order to ascertain if the examiners could distinguish between the symptoms attributable to the service-connected PTSD and those due to the personality disorder. They have done so, as is reflected below. In so doing, the examiners have conducted a careful study of the entire record, which reflects a long history of psychiatric impairment, which existed since the veteran's childhood and for which he and his parents underwent extensive pre-service evaluation. The extensive pre-service records clearly contradict the veteran's denial of pre- service psychiatric history, which was noted at the time of the entry examination. Some of the veteran's current symptoms, including social isolation, depression and withdrawal, were, in fact, noted prior to service and are indicative of the significant personality disorder he had at that time and which, according to the record, continues to persist. The record clearly reflects that while some of the psychiatric symptoms are part of PTSD, much of the veteran's maladjustment is life-long and has been attributed to various factors, such as a learning disability, brain damage, and parental influence. Over the years, the examining physicians, psychologists, and counselors have reported the veteran's manifestations of his disability as flashbacks, nightmares, hypervigilance, and an inability to develop and sustain relationships, which have been associated with his PTSD. A number of physicians have further noted that, although the veteran suffers from PTSD, his overwhelming problem is his personality disorder manifested, according to those examiners, by feelings of fearfulness, poor interpersonal functions, impaired judgment, and circulatory speech. It is apparent that, although the veteran exhibits many overlapping symptomatology, the professional medical examiners are able to differentiate, through personal examination of the veteran and review of his medical records, between his service-connected PTSD and his nonservice-connected personality disorder. The medical opinions expressed consistently attribute the veteran's overall disability as a mixture of symptoms of PTSD and personality disorder with multiple components. Further, the medical opinions have consistently attributed no more than 50 percent of the veteran's overall disability to PTSD, with the remainder of his difficulties attributed to his personality disorder. A board of two VA psychiatrists in March 1996, following examination of the veteran and his records, assigned a GAF score of 40, based on the combination of PTSD and personality disorder. The Board notes that, pursuant to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), scores between 31 and 40 denote that there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or there is major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is falling at school). In support of the assigned score, the physician noted that the veteran has a major impairment in family relations, work, judgment, and thinking. On the other hand, the above-mentioned examiner noted that if the veteran had no personality disorder, the PTSD symptomatology might result in a GAF score of around 60. The Board notes that scores between 51 and 60 denote 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). Subsequent psychiatric examination reports note that the findings were remarkably similar to those of earlier examinations. He was still living a similar lifestyle and he still had not received any hospital treatment or been prescribed any medication for his psychiatric disability, however diagnosed. On most recent VA examination, conducted in June 2000, he did not present noteworthy emphasis on symptoms of PTSD, although he did mention some in passing. The examining physician, after examination of the veteran and review of the records, noted that even the veteran's Social Security Administration records did not alter the consistently given diagnoses in the veteran's case. The physician reiterated that personality disorder plays a prominent role and was indeed the basis of his original award of Social Security, although PTSD was later noted on review, as well as substance abuse (alcohol). Again, a 50/50 split was noted between PTSD and personality disorder to account for the veteran's overall disability. He assigned a GAF score of 40, reflecting the veteran's major impairment in the overall condition, which he offered as chronic, moderate PTSD; alcohol abuse, in remission; a remote history of learning disability; and personality disorder. The Board notes that under normal circumstances a GAF score of 40 would connote serious symptomatology indicative of an inability to obtain and maintain gainful employment. However, in the veteran's case, the overall score includes both his service-connected PTSD and a nonservice connected personality disorder. The medical experts have been able to differentiate between the two and have consistently opined that the veteran's primary problem is his personality disorder, although there is some overlapping symptomatology. In review of the numerous medical evaluations, the veteran's PTSD has consistently been described as moderate, with no medical opinion offered that his symptomatology attributable to his PTSD has increased in severity. The evidence does indicate that the veteran has impaired interpersonal relationships, as noted during his most recent examination, yet other symptomatology medically associated with PTSD have not been clinically shown to have manifested to such severity as meeting the criteria for a 50 percent evaluation under either the former or current criteria. In the absence of clinical evidence of considerable impairment attributable to the veteran's PTSD in his ability to establish or maintain effective and wholesome relationships with people and by reason of psychoneurotic symptoms his reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment (under the former criteria), or a 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships (under the revised criteria) due to PTSD, and only his service-connected PTSD, the criteria for the next higher, 50 percent evaluation, under either criteria, simply are not met. It follows that the criteria for any higher evaluation (70 or 100 percent) likewise are not met. The above determinations are based on applicable provisions of the VA's rating schedule. Additionally, however, the Board finds that the veteran's PTSD is not shown to be so exceptional or unusual as to warrant an evaluation in excess of 30 percent on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). In the instant case, there has been no assertion or showing that the service-connected PTSD, and only the service-connected PTSD, has caused marked interference with employment (i.e., beyond that contemplated in the assigned evaluation), has necessitated frequent periods of hospitalization, or otherwise has rendered impracticable the application of the regular schedular standards. Indeed, the veteran does not take nor has he ever taken medication for his psychiatric disorder, nor has he ever been hospitalized for treatment of a psychiatric disorder. Rather, as noted above, the examining psychiatrists have consistently found moderate social or occupational impairment due to his PTSD. In the absence of evidence of the above-mentioned factors, the Board need not remand the matter for compliance with the procedures set forth in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 237, 239 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the claim for an evaluation in excess of 30 percent for PTSD must be denied. In reaching this 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 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). B. Competency The issue of whether or not a veteran is competent to receive direct payment of VA benefits is governed by 38 C.F.R. § 3.353(a), which provides that a mentally incompetent person is one who, because of injury or disease, lacks the mental capacity to contract or to manage his or her own affairs, including disbursement of funds without limitation. Unless the medical evidence is clear, convincing, and leaves no doubt as to the person's incompetency, the rating agency will make no determination of incompetency without a definite expression regarding the question by the responsible medical authorities. Determinations relative to incompetency should be based upon all evidence of record and there should be a consistent relationship between the percentage of disability, facts relating to commitment, or hospitalization and the holding of incompetency. See 38 C.F.R. § 3.353(c). The Board notes that there is a presumption in favor of competency. Where reasonable doubt arises regarding a beneficiary's mental capacity to contract or to manage his or her own affairs, including the disbursement of funds without limitation, such doubt will be resolved in favor of competency. See 38 C.F.R. § 3.353(d). The VA board of two psychiatrists, following examination of the veteran and his records in March 1996, noted that he was almost totally insightless and had no plan or perceived need for mental health treatment. His financial management skills, by his own testimony and corroborated by his parents, were found to be extremely poor. At the time, he was turning all of his income over to his parents for handling, which was to be applied to his credit card debt, and they, in turn, would supply him with their own money for his living expenses. He did not have a formal financial fiduciary appointed. It was the examiners' recommendation that, in view of the veteran's manifest mismanagement of his financial affairs, he be rated as incompetent for VA purposes and that a fiduciary agent be appointed for him. Based on the recommendations of the two examining physicians, the RO, in a June 1996 rating action, proposed to rate the veteran incompetent for VA purposes under the provisions of 38 C.F.R. § 3.353. After following appropriate due process procedures, the RO implemented the proposal to rate the veteran incompetent for VA purposes in a September 1996 rating decision. Following VA examination in January 1998 by one of the two physicians who had examined the veteran in March 1996, the physician noted that the issue of competency in this case was an unusual one in that in his forty years of practice, he found it to be very unusual for a finding of incompetency to be made for other than an organic brain syndrome or a psychosis, neither of which had been diagnosed in the veteran's case. On the other hand, the psychiatrist noted that the veteran's insight and judgment had not improved since the time of his last examination and it would be in the veteran's own best interest to have a fiduciary appointed. The psychiatrist further noted that this opinion was not because of the veteran's PTSD or his alcohol abuse, but rather because of his personality disorder and its associated operating style. The veteran received an unannounced visit in August 1998 by a VA field examiner who had not previously met the veteran. To the examiner, the veteran seemed to be doing well. It appeared that the veteran was able to provide for his living needs and was functioning independently in the community, with some help from his parents as a support system. Based on the one visit and personal observation, it was the field examiner's opinion that the veteran was competent for VA purposes. In an October 1998 addendum to his report, the field examiner noted that the VA had left the veteran on supervised direct pay for the coming year to allow him more time to demonstrate his ability to handle his affairs. Following the above-mentioned unannounced visit to the veteran, the field examiner related that, in comparison to many other VA beneficiaries, who are clearly incompetent, the veteran seemed to be doing well. As previously noted, the veteran was providing for his living needs and appeared to be functioning independently in the community, with some help from his parents. When pressed for a clear statement of whether the veteran was competent versus incompetent, the examiner, without additional psychiatric evaluation, would have to state competent for VA purposes. In November 1998, the other VA physician who had examined the veteran in March 1996 re-examined the veteran. Again, the physician reviewed the records in conjunction with the examination and noted that it appeared to him that the above- mentioned field examiner did not have the benefit of having the veteran's medical records and previous evaluations when the opinion was offered concerning the veteran's competency. It was the physician's opinion that it would appear to be in the veteran's best interest for him to be declared incompetent for VA purposes, given his gross difficulties with managing financially and the massive debt that he had accumulated. Further, the psychiatrist offered that it would be difficult to ascertain that the veteran's financial affairs were managed satisfactorily even when he had assistance as he was not the sort of individual who could be given a lump sum and be counted on to not misuse the money. Thus, it would appear that if money were to be distributed to him, it should be done in relatively small increments, perhaps covering several days to no more than a week at a time. Following VA psychiatric examination in June 2000, the physician noted that the veteran's approach to his money management matters had not varied much from previous descriptions, except that he now was in bankruptcy proceedings. The examiner further noted that the veteran had continued in the same lifestyle previous indicated and that, because of his severe personality disorder, he lacked the capacity to manage his own affairs, including the disbursement of funds without limitations. In the veteran's case, there is one field examiner who weighs in favor of the veteran's competency and two VA examining psychiatrists who are against such a finding. The field examiner based his opinion on personal observation during an unannounced visit to the veteran's home. The VA psychiatrists' opinions are based on multiple examinations of the veteran, both before and after the field examiner's visit to the veteran, and reviews of the veteran's records. Further, the field examiner's opinion was made contingent, in that he notes "Without additional evaluation from VAMC (psychiatric), and pressed for a clear statement of competent or incompetent, this examiner would have to state competent for VA purposes." The veteran was subsequently examined and the VA psychiatrist who conducted the examination, and reviewed the record, offered the medical opinion that the veteran was not competent for VA purposes to handle his own funds. In light of the definitive opinions of the medical authorities, based on personal examination of the veteran and of the record, the Board concludes by a preponderance of the evidence that the veteran is not competent for VA purposes to manage his own affairs, including the disbursement of funds without limitation. ORDER A disability evaluation in excess of 30 percent for post- traumatic stress disorder is denied. The veteran is not competent for VA purposes to manage his own affairs, including the disbursement of funds without limitation. N. R. ROBIN Veterans Law Judge Board of Veterans' Appeals