Citation Nr: 0511125 Decision Date: 04/19/05 Archive Date: 04/27/05 DOCKET NO. 93-20 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to a rating in excess of 30 percent for post- traumatic stress disorder based on an initial award. 2. Whether the veteran may be considered competent for Department of Veterans Affairs (VA) benefit purposes. REPRESENTATION Appellant represented by: Peter J. Meadows, Attorney at Law WITNESSES AT HEARINGS ON APPEAL Veteran and his parents ATTORNEY FOR THE BOARD D. L. Wight, Counsel INTRODUCTION The veteran served on active duty from February 1974 to January 1976; he had no foreign service. This matter initially came 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. In that rating decision, the RO implemented the May 1992 Board decision that awarded service connection for post-traumatic stress disorder (PTSD) and assigned a 30 percent disability rating, effective from July 1990, the date of receipt of the veteran's claim. The veteran perfected a timely appeal of the initial 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 Member of the Board in August 1993. In an October 2000 decision, the Board denied the veteran a rating in excess of 30 percent for PTSD based on an initial award and found that the veteran was not competent for VA purposes to manage his own affairs, including the disbursement of funds without limitation. The veteran appealed the October 2000 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2001 Order, the Court granted the Secretary's Motion for Remand and to Stay Proceedings, and remanded the case to the Board for another decision, taking into consideration matters raised in the Motion, namely, consideration and compliance with the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000). After receiving additional argument and evidence from the veteran and his representative in support of the appeal, along with a signed waiver of RO jurisdiction of that evidence, and a waiver from the veteran and his representative of any additional assistance or case development in connection with both the Motion for Remand and the provisions of the Veterans Claims Assistance Act of 2000, the Board issued a decision in April 2002 denying a rating in excess of 30 percent for PTSD and holding that the veteran was not competent for VA purposes to manage his own affairs. The veteran then appealed the Board's April 2002 decision to the Court. In a January 2003 Order, the Court granted the parties' Joint Motion for Remand and to Stay Proceedings. Pursuant to the actions requested in the Motion, the Court vacated the Board's April 2002, decision, and remanded the appeal to the Board for readjudication with consideration of the Veterans' Claims Assistance Act of 2000, Pub. L. No 106-475, 114 Stat. 2096 (Nov. 9, 2000) (VCAA). Thereafter, in September 2003, the Board again remanded the case to the RO for further development. The RO completed the requested development and the case has been returned to the Board for further appellate consideration. Finally, it is noted that on a number of occasions, the Board has referred to the RO the veteran's claim for a total disability rating due to individual unemployability (TDIU). This issue was given some initial consideration in the supplemental statement of the case provided to the veteran in August 2004. However, the Board notes that the veteran was not provided his appellate rights, nor has the issue otherwise been fully developed for appellate review. Accordingly, assuming jurisdiction of the issue of entitlement to a TDIU, for a period prior to April 6, 2004, would be premature at this time. 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 report of an April 6, 2004, VA examination shows that the veteran's PTSD results in total occupation and social impairment and his PTSD alone renders him unemployable. 3. Prior to April 6, 2004, examining physicians, psychologists, and counselors had consistently attributed the veteran's overall psychiatric disability and impairment, as a mixture of symptoms of PTSD (for which he is service- connected) and personality disorder (for which he is not service-connected and which is not a disease within the meaning of the applicable regulation), with multiple components, such as alcohol abuse. 4. Prior to April 6, 2004, examining physicians, psychologists, and counselors had differentiated the veteran's service-connected PTSD, manifested by flashbacks, nightmares, hypervigilance, avoidance, depressed mood, anxiety, suspiciousness, irritability, chronic sleep impairment, and an inability to develop and sustain relationships, from his nonservice-connected personality disorder, manifested by feelings of fearfulness, poor interpersonal functions, impaired judgment, and circulatory speech. 5. From July 1990, the effective date of the award of service connection for PTSD to April 6, 2004, the veteran's PTSD, and only PTSD, is shown to result in no more than definite occupational and social impairment prior to November 7, 1996, or 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 since November 7, 1996. 6. Unanimous VA examining psychiatrists' opinions, based on examination of both the veteran and of the record, are 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 of 100 percent for PTSD from April 6, 2004, are met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.130 Diagnostic Code 9411 (2004). 2. The criteria for a disability evaluation in excess of 30 percent for PTSD from the effective date of the grant of service connection to April 6, 2004, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.130 Diagnostic Code 9411 (1996 & 2004). 3. 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. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.353 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS During the pendency of this appeal, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law and codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002). In additions, regulations implementing the VCAA were published at 66 Fed. Reg. 45,620, 45,630-32 (August 29, 2001) and codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2002). The liberalizing provisions of the VCAA and the implementing regulations are applicable to the present appeal. The Act and the implementing regulations essentially eliminate the requirement that a claimant submit evidence of a well-grounded claim, and provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. In addition, VA is required to inform the claimant to submit any pertinent evidence in the claimant's possession. The case currently on appeal has been ongoing since the RO's rating decision in May 1992, which granted the veteran entitlement to service connection for PTSD, assigning the disability a 30 percent rating, and since September 1996 on the issue of the veteran's incompetence when the RO determined that the veteran was incompetent for VA purposes. The Board notes that a substantially complete claim was received prior to the enactment of the VCAA. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the United States Court of Appeals for Veterans Claims (Court) held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA- administered benefits. Id. at 119. The Court further held that VA failed to demonstrate that, "lack of such a pre-AOJ- decision notice was not prejudicial to the appellant, see 38 U.S.C.A. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that "[i]n making the determinations under [section 7261(a)], the Court shall . . . take due account of the rule of prejudicial error")." Id at 121. However, the Court also stated that the failure to provide to provide such notice in connection with adjudications prior to enactment of the VCAA was not error and that in such cases, the claimant is entitled to "VCAA-content complying notice and proper subsequent VA process." Id. at 120. In the present case, the veteran has been provided with two Statements of the Case (one on each issue before the Board - in January 1993 and March 1997) and no less than seven Supplemental Statements of the Case (August 1993, June 1996, March 1998, May 1998, February 1999, June 2000, and August 2004). In addition, he was provided with letters in December 2003 and January 2004 addressing the VCAA and its relationship to his current appeal. Although the RO did not specifically inform the veteran to submit any pertinent evidence in his possession, it informed him of the evidence required to substantiate his claim, the information required from him to enable VA to obtain evidence on his behalf, the assistance that VA would provide to obtain evidence on his behalf, and that he should submit such evidence or provide the RO with the information necessary for the RO to obtain such evidence on his behalf. Therefore, the Board believes that he was on notice of the fact that he should submit any pertinent evidence in his possession. Moreover, he has been afforded numerous opportunities to submit additional argument and evidence throughout the appeal process. In May 2004, the veteran's attorney reported that he and the veteran had no other evidence to offer nor knew of any evidence for VA to obtain. Similarly, a July 2004 VA report of contact indicates that the veteran reported that he had no further medical evidence to submit in connection with his appeal. Accordingly, the Board finds that the duties to assist set forth under the VCAA have also been fulfilled in that all evidence and records identified by the veteran as plausibly relevant to his pending claim have been collected for review. The record contains numerous private and VA pre- and post- service outpatient treatment records and Social Security Administration records. The veteran has undergone no less than seven VA psychiatric and psychological examinations (July 1990, August 1990, March 1996, April 1996, January 1998, November 1998, June 2000, and April 2004). He has been the subject of several VA social and industrial surveys (August 1990, June 1992 and March 1996) and several VA field examinations (October 1996, September 1997, August 1998, August 1999, October 2000, August 2002, and September 2003). He has testified at personal hearings before a hearing officer (June 1993) and before the undersigned Member of the Board (August 1993). The Board has remanded the case to the RO four times (January 1996, November 1997, and September 2003) for further development, to include review of the record, for psychiatric examinations, and for medical opinions. Under the circumstances, and given the medical opinions offered (based on review of the record and examination of the veteran) throughout the duration of the appeal and the evidence received (both VA and private), no further assistance is necessary to comply with the requirements of this new legislation, or any other applicable rules or regulations regarding the development of the pending claims. I. Factual 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 his noncommissioned office in charge (NCOIC) and commanding office (CO) were harassing him. He was taken to the Correctional Custody Facility where, he reported, he was harassed and beaten up. He escaped from that facility; got in touch with his parents; and was seen in the emergency room at Madigan Army Medical Center. On physical examination, bruises were noted, but no other injuries. At the time, he stated that he would be harassed and injured again if he were returned to the Correctional Custody Facility. While hospitalized, his behavior on the ward was appropriate and without evidence of major psychiatric disabilities. After psychiatric evaluation 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 a military setting. He was felt to represent more of a liability than asset to the military. In a December 1975 statement, the veteran's unit commander stated 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 in January 1976. His certificate of discharge was upgraded to Under Honorable Conditions in 1977. At the time of his claim for service connection for PTSD, filed in July 1990, the veteran reported that, in addition to that disability, he had had a personality disorder and learning disability since childhood and that both had been characterized as "severe" by the Social Security Administration. The veteran's parents, in a letter of July 1990, provided a "psychological profile" of the veteran, detailing his symptoms of nervousness, anxiety, depression, anger, disillusionment, nightmares, interrupted sleep, suicidal ideation, and limited social interaction. The veteran underwent a Vet Center intake medical evaluation in July 1990 during which he 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. He stated that he had had considerable difficulty in school, had been told that he had a severe learning disorder, and had used alcohol regularly since age 14. He reported depression since service but no treatment until 1990. The social worker concluded that the veteran had been clearly traumatized and significantly affected by childhood and military experiences. 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 personal examination of the veteran, the examining physician's impression was that the veteran suffered from PTSD, but his overwhelming problem was his personality disorder, with paranoid and schizoid features, that pre-existed his military service and was aggravated by the episode at the Correctional Custody Facility. The examiner noted that the veteran had not functioned very well in high school, that he had had a poor self image, that he had had difficulty with social relationships, and that he had performed poorly in school due to a learning disability. He used no medication for his psychiatric disorder, but reportedly used alcohol to relieve nightmares and distress. The psychiatrist 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. On examination at that time, the veteran had an anxious affect, spoke in clear, pressured tones, was preoccupied by military experiences, and had poor insight and fair judgment. He was described as alert and oriented, presenting no reports of hallucinations, thought disorders, or delusional thinking. The veteran's symptoms of numbing and restriction of affect, with rage and anger, were felt by the examiner to be due to both his personality disorder and PTSD. Submitted were treatment records compiled in 1990 from Seattle Mental Health Institute which reflect that the veteran was not working and considered to be disabled by the Social Security Administration due to a learning disorder. These records refer to a review of pre-service records reflecting such notations as brain damage, a learning disorder, adjustment disturbance of adolescence, and passive- aggressive personality disorder. Also recorded were symptoms the veteran claimed to be experiencing as a result of traumatic incidents in service. (The symptoms are essentially the same as reported above.) A diagnosis of PTSD was made. In a statement of May 1991 the veteran's father wrote that the veteran was raised to be a well mannered and likable person, and that, in fact, he was well-liked by fellow students and his teachers. The father recounted a version of events the veteran experienced in service, including "horrible torture and abuse," which caused nightmares, despair, depression and alcohol abuse. Inasmuch as there was a question as to whether the veteran suffered from PTSD as a result of the reported, but unverified, 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 had been adopted by his parents when he was an infant; he had a learning disorder while in school; he started using alcohol before service and abused alcohol considerably from 1975 to 1978, he was still drinking because it calmed him; and he lived alone in his own home, which had been 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 did not engage in significant social relationships because he did not feel fit. He claimed that VA was flying helicopters over his house, and had been observing his movements. The social worker commented that due to his alcohol abuse, it was recommended that the veteran not be permitted to handle funds. On mental status examination, his affect was excellent and showed no signs of a schizoid type. He showed some signs of the hypervigilant suspiciousness seen in more classic cases of PTSD. The veteran denied using psychiatric medication but indicated 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, with an effective date in July 1990, the date of receipt of the veteran's claim. The disability was assigned a 30 percent rating. In June 1993 the veteran and his parents appeared at a hearing held before a hearing officer at the RO, during which he asserted that he was seeking a permanent 100 percent rating, effective from the date of the award of service connection. He testified that he was in receipt of Social Security disability benefits; that his illness was longstanding; and that a private medical care provider had told him that he was totally disabled. He further testified he had terminated his PTSD treatment because the treatment was only aggravating his stress. In August 1993, the veteran and his parents appeared at a Board hearing, which was held before the undersigned. During the hearing, the veteran compared his situation to that of other veterans who, he stated, were evaluated as 100 percent disabled. He testified that he had not worked since 1987, when he was a basic laborer. He stated that he had not completed high school because of a learning disorder. He claimed that he was receiving no medication, nor was he involved in counseling. He related that he spent many hours each day working on his claim for compensation. He was able to do his own shopping and driving, but relied on his parents for help with paying the bills. He related experiencing nightmares, flashbacks, depression and anxiety. The veteran's mother testified that he 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 pertains specifically to the veteran or his claim. Pursuant to one of the Board's remands, reports from The Children's Orthopedic Hospital were received reflecting the veteran's evaluation and treatment for passive-aggressive personality disorder between the ages of nine and seventeen. These pre-service medical records describe him as exhibiting an emotional reaction to his mother's over-preoccupation with him, and with numerous obsessive thoughts of anger and hurting. He was assessed as having a significant and "very serious" personality disturbance. Also noted was the possibility of brain damage; an abnormal electroencephalogram was reported as was the fact that he had been treated with anti-convulsive medications. The medical 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 for a learning problem with some psychological component of etiological significance. A 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 he 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 he had a history of learning disabilities, with memory problems, confusion and general frustration, as well as a personality disorder. The veteran reported being depressed since childhood. 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 subsequent continuation thereof, was the veteran's overall disability comprised of 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, relate that, based on the veteran's own statements and materials he presented, the veteran met the criteria for a diagnosis of PTSD. The trauma in question was his incarceration and associated treatment, or handling, in a Correctional Custody Facility during a period when 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. The counselor had found no evidence of hallucinations. Although some paranoid ideation was seen, it was not of a psychotic or delusional nature. The veteran expressed a distrust of large institutions. The counselor determined that the veteran's daily activities, social functioning, and living situation were all strongly and negatively impacted by his illness. The examiner 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 counselor concluded 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. The counselor noted that the veteran experienced almost overwhelming stress and anxiety when faced with ordinary situations, to which most people give little or no thought. Records from Seattle Mental Health Institute dated in the early 1990s show a history, dating back to age 13, of the veteran's use of alcohol and extensive physical abuse "as he grew up." Following extensive review of the veteran's medical records from the time he was 9 through 16, his treating physician found evidence of brain damage, a learning disability, adjustment disorder of adolescence, and passive- aggressive personality disorder. The veteran's parents were described as being very rigid. The examiner concluded 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, which included in pertinent part, that the veteran had discontinued any contacts with VA facilities because he claimed that the treatment was not effective and that he did not expect to get any better. It was noted in the record, and the veteran confirmed, that he had made two 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 rational in manner. He claimed that he had not worked since 1987 and that he spent 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 were 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. The veteran's parents, who were present throughout the interview, concurred with the veteran's account. 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. Prior to preparing their report, they also considered the April 1996 report concerning VA psychological testing. At the insistence of the veteran and his parents, he was evaluated in his parents' presence. 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, explaining that some of his credit card spending was recompense for the treatment he received in the military and the government's failure to compensate him in a just manner. He led an isolated life. He related that he got "totally blitzed," up to eight times a month, on alcohol. At other times, he maintained periods of sobriety, primarily so that he had a clear head to work on the intricacies of his case, at times, 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 in-patient, 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 experienced intrusive thoughts and, at times, dreamt about his trauma in the service. During his many different security guard jobs, he stated that he sometimes had flashbacks of the time he had been beaten by military policemen. He also related that he had had a number of contacts with legal authorities as a result of assault and intoxication charges. 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 had 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. In October 1996, a VA field examiner visited the veteran at his residence. His parents were also present during the interview. He was not taking medication for his PTSD. He was dressed in shorts, no shoes, and a shirt with the sleeves cut off. He wore a variety of service medals including the Vietnam service medal, good conduct medal, sharp shooters badge, and the combat infantryman badge (CIB). He was open and cooperative during the two hour long interview. He felt that the government had let him down and that he was owed a total rating. He had not been able to maintain full employment and had had numerous brushes with the law. At one time, he had attacked a Seattle police officer. His biggest present problem was alcohol abuse. The veteran had gone out drinking from 1:30 pm the afternoon before the field examination to 7:00 am the morning of the examination. He had a home office "loaded with military and [Vietnam] paraphernalia with stacks of books relating the Vietnam, Social Security, the United States Constitution, and individual rights." He also had the United States flag, a POW flag, and a Vietnam flag hanging from his walls. He was organized having everything properly filed, either in a cabinet or in his mind. He left the phone off the hook, so he did not have to talk with anyone. His parents shared his belief that the veteran's condition was the government's fault. Regarding his capacity to manage funds, the field examiner noted that the veteran used his Social Security and VA benefits for gas, food, and alcohol. His parents helped him out by paying all of his routine monthly living expenses. He had a lot of credit card debt. He stated that if he were to receive a retroactive award, he would not give the credit card companies "one red cent," as they were part of his problem by giving him the cards. It was felt the veteran should continue to directly receive his monthly VA benefit check, as having a payee would not be good for his mental condition. It was noted that the veteran had no social life. He was anti-social and paranoid with no trust in people. He spent his time at home or at different parks. He also read a lot. 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. The report of a September 1997 VA field examination indicates that the veteran was visited unannounced, as the examiner was unable to reach him by phone. The veteran's history included depression/anxiety, poor memory, difficulty concentrating, sleep disturbance, low coping skills, poor planning ability, easy distractibility, and a learning disabilities. The veteran reported that he was deemed incompetent to manage his funds because he had ran up a large credit card debt. He admitted to having $11,000 to $13,000 in collections. He insisted that he was not incompetent and would not file for bankruptcy. He intended to spend with more discretion and pay his debts. His monthly income of $274 from VA and $440 from Social Security disability benefits went to eating out, socializing with "the guys," buying books, and buying "war stuff." He had no savings. It was felt that his parents provided him with considerable financial help. The field examiner noted that he was worried about the veteran. The veteran was thrilled to show off his war related items. He had six military assaults rifles with plenty of ammunition. He also had a cached supply of canned food, web gear, and a portable power generator. It was felt that the veteran was living in a "make-believe world." His social life consisted of "hanging out with the guys at their favorite watering hole reliving the War." He reported that he only drank cocktails and only smoked when he drank. The veteran's house was well maintained inside and out; however, it was a "bit untidy" when the field examiner arrived as the veteran was sorting his war stuff and he had books piled everywhere. 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 "relatively little" as to 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 that he 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 many 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 had 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 psychiatrist conceded that the veteran's case was most unusual and he emphasized that the veteran's incompetency arose not from PTSD or alcohol abuse, but from his personality disorder and his operating style. The report of an August 1998 VA field examination and an addendum report of October 1998 reflect that a VA field examiner visited the veteran at his home unannounced. The veteran indicated that this was best since the phone was usually off the hook because of the number of bill collectors calling. The reports note that the veteran presented well and his home was clean and orderly. He was friendly and oriented. To the examiner, the veteran seemed to be doing well especially when compared to other incompetent veterans. 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, although further review in another year was recommended. In November 1998, VA, P. P., M.D., one of the two psychiatrists who had examined the veteran in March 1996, again examined the veteran. Such was requested by the RO because the report of an earlier field examination was not in the file at the time of earlier psychiatric examination. 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. On that occasion, the veteran was described as being fully oriented, very emotionally detached, simplistic in his general attitude, and having poor eye contact. 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. He was described as being "his own worst enemy." In making such determination, the examiner acknowledged the report of the field examiner, especially the reference to the veteran's keeping a clean house, but pointed out that the veteran had difficulty managing his finances. The report of an August 1999 VA field examination indicates that the veteran was currently enrolled in several morning programs relating to alcohol abuse. The veteran did not receive phone calls, as he was afraid of calls from bill collectors. He had recently received a driving under the influence citation after driving off the road in a single car, roll-over accident. He had taken several pain pills for pain to his gums and drunk a couple of beers. He then became sleepy and drove off the road. He was ambulatory and able to care for his personals needs. He was friendly, open, and cooperative. He had what appeared to be a simple conceptual ability and when asked for specific details of his personal life, he became vague. His conversation was friendly, but he would go off on tangents. It was felt that he appeared to be less competent to handle funds than he was on a prior visit and that he was currently incompetent for VA purposes. He did not have the concentration or insight of thought to maintain significant employment. A. W., M.D., re-examined the veteran in June 2000, and reviewed the veteran's records, including his Social Security Administration records that 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, but estimated that the sum was approximately $100,000. 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 alleged 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 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 had markedly impaired his reliability and flexibility so that a very considerable amount of industrial impairment was present. The examiner noted that there was some overlap 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 overlapping 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. The examiner cautioned, however, that the GAF scale was never intended to be used in the adjudication process and such use continued to be controversial. He added that he was "very impressed" with the veteran's high degree of "disability conviction," which was accompanied by a "remarkable sense of entitlement." In a letter drafted during the summer of 2000, Dr. K.L.S. and B.S., MSW, reported that the veteran had been seen in the VA Addiction Treatment Center since January 1999. He had been compliant with his treatment plans in order to reach his stated goals. He had been clean and sober for well over a year and his psychiatric disorders had been stabilized. It was noted that he had brought in a collection of receipts for various bills from the last two years. He had demonstrated the ability for personal responsibility toward this matter. It was further noted that he had not shown any concern to think that he was not capable of being in charge of his own funds and it was felt that he was not in the need of a payee. However, Dr. K.L.S. in an August 2003 email message wrote that there seemed to be ample evidence that the veteran was not able to handle his own funds and he would not support the veteran being his own payee. A VA field examiner visited the veteran in October 2000 at his home. As with prior visits, he was friendly, open, and cooperative. He had fair to good orientation to time, place, and event. He continued to attend Alcoholic Anonymous meetings. He was vague about details in his personal life and his finances. It was felt that the veteran could not manage his funds due to poor judgment. VA outpatient treatment records from November 2000 to May 2001 show that the veteran attended group therapy at the Addiction Treatment Center. He denied any depressive symptoms or changes with sleep or appetite during a visit in November 2000. He also denied any suicidal or homicidal ideations. He was attentive to other group members and offered ideas. In December 2000, he reported that his mood was stable with no holiday sadness. He was compliant with medication. He reported depression that came and went. It was a 1 on a scale from 1 to 10. However, a January 2001 record notes that his anxiety remained high and was worried about how he would support himself in his old age. He reported depression in February 2001. During his treatment, he reported that he was able to pay his own bills and was seeking to regain the ability to be in charge of his own money. Submitted by the veteran's attorney in January 2002 was a medical statement from a private physician who identified himself as specializing in internal medicine. This doctor related that he had thoroughly reviewed the Board's "decision file" pertaining to the veteran. In the statement, the physician reiterated the findings of the veteran's spring 1996 VA psychiatric and psychological examinations which found the veteran incompetent to manage his own financial affairs and that these examiners had pointed out that the veteran, as a result of PTSD, has severe social and occupational impairment. The physician noted that, in November 1998 and in June 2000, the veteran underwent more psychiatric examinations, the reports of which mention his difficulty in managing debt and recommendation of declaration of incompetence. The reports also mention that the veteran was in a substance abuse program as a result of a DWI arrest. Finally, the private physician offered that, in his opinion, the service-connected PTSD had caused the veteran severe social and occupational impairment, and that it was not at all surprising that he was incapable of acquiring and holding down a job with such a disability. Another field examination of record was conducted in August 2002. The veteran was ambulatory and able to care for his personal needs. He was neatly dressed in clean, casual clothing with good grooming. He took no medication. He was again friendly, open, and cooperative. He showed good orientation to time, place, and event. He appeared to be open, but continually turned the topic of conversation to his VA appeal. He continued to attend AA meetings. He spoke bitterly of recently being turned down when he tried to purchase a firearm for target practice. He stated that he was turned down because of his incompetency rating. Unlike prior visits, the veteran was able to discuss his finances adequately giving a fair accounting of his finances. His mother reported that she had turned the bill paying responsibility over the veteran who was doing a good job paying his bills and making ends meet on his limited income. An April 2003 VA outpoint treatment record indicates that the veteran had called to report that "he doesn't have a mind anymore." He reported stress from the VA benefits claim process. He was also unhappy with his gardener who had cut down all of his bushes. The veteran was advised to seek care at the closest VA hospital. However, the evidence does not show that he sought subsequent VA treatment. The most recent VA field examination was conducted in September 2003. The veteran was alert and oriented times three. For the most part, he was open and cooperative. He admitted significant financial problems which he attributed to being underrated by VA. It was felt that the veteran was capable of managing his current income, but was not realistic about how he could live within his means. He reported that he "worked tirelessly to help veterans get their just benefits." He was somewhat social isolated with routine contact only with his parents. Pursuant to the Board's prior Remand, the veteran was afforded a VA compensation and pension examination conducted by a Board of two psychiatrists on April 6, 2004. The psychiatrists noted that they had interviewed the veteran for two hours and 15 minutes, reviewed his VA claims folder, and spoke with his mother. The veteran was markedly obese and had a self styled haircut which was cut very close up to his eye level and then bushy on top. He was alert and cooperative. His speech was generally easy to understand in terms of his words; however, he obsessively went back to talk about entitlement issues. He spoke in a normal rate and volume. His obsession with his compensation issue made it difficult to engage in a conversation. His mood was irritable, but generally in control and his affect was mood congruent. He reported continued daily and nightly symptoms of poor sleep, nightmare, intrusive thoughts, and frequent digestive problems that he related to his time in the correctional facility in-service. Anytime he took a shower, he was flooded with traumatic memories of the abusive treatment he claimed he had at the correctional custody facility during service. The following conditions were diagnosed: PTSD, chronic, severe; alcohol dependence, current status unclear; longstanding learning disabilities; and a personality disorder, not otherwise specified, with narcissistic paranoid and schizoid features. A GAF of 38 was indicated. The examining psychiatrists felt that the veteran's PTSD was severe and the resulting disability severely impaired his reliability and flexibility. It was difficult to separate the veteran's PTSD symptoms from his personality disorder. However, it was opined that the veteran was unemployable based solely on his PTSD. It was further felt that his impairment which some had related partially to his personality disorder could as likely as not be from his PTSD. He was terribly anxious and disorganized and obsessed with the injustices that he perceived to have befallen him. It was felt that his in-service trauma of being assaulted resulted in his PTSD and that he remained fixated on issues involving this incident. The examining psychiatrists did not believe that pre-service or post-trauma traumas played a significant part in his present illness. They noted that they concurred with the assessment of earlier examiners that the veteran was not competent to handle his funds. His learning disability was a contributing factor in the finding of incompetency. Although, his parents reported that he could manage his own affairs, they provided further evidence of his having trouble with his finances and paying all of his bills. His mother reported that he owed his parents much more than $100,000. He had gone through bankruptcy and was no longer using credit cards. He drank up to 20 drinks of Irish whisky a night when he drinks with his friend. He drank one to two nights per week with his friend. II. Analysis Essentially, the veteran is asserting that his PTSD is more severely disabling than 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 since the effective date of the grant of entitlement to service connection for PTSD, in July 1990. He further maintains that, despite the seriousness of his disability, he is competent to manage his financial affairs, including the disbursement of funds without limitation. In the overall analysis of this case, the Board notes that the United States Court of Appeals for Veterans Claims (Court) has offered guidance on the assessment of the probative value of medical opinion evidence. The Court has instructed that it should be based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical opinion that the physician reaches. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Further, the Board is charged with the duty to assess the credibility and weight given to evidence. See Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. See Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). A. Evaluation of PTSD 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 (2004). 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, where the question for consideration is propriety of the initial evaluation assigned, as it is in this case, 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. As previously noted, 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. Hence, 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. 52,695- 52,702 (1996). The Board notes that in Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit overruled Karnas v. Derwinski, 1 Vet. App. 308 (1991), to the extent it conflicts with the precedents of the Supreme Court and the Federal Circuit. See Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991) (The Court held that where the law or regulations change while a case is pending, the version most favorable to the claimant applies, absent Congressional intent to the contrary). In VAOPGCPREC 7-2003, the General Counsel held that Karnas is inconsistent with Supreme Court and Federal Circuit precedent insofar as Karnas provides that, when a statute or regulation changes while a claim is pending before the VA or a court, whichever version of the statute or regulation is most favorable to the claimant will govern unless the statute or regulation clearly specifies otherwise. The General Counsel held that the rule adopted in Karnas no longer applies in determining whether a new statute or regulation applies to a pending claim. The General Counsel indicated that pursuant to Supreme Court and Federal Circuit precedent, when a new statute is enacted or a new regulation is issued while a claim is pending before VA, VA must first determine whether the statute or regulation identifies the types of claims to which it applies. If the statute or regulation is silent, VA must determine whether applying the new provision to claims that were pending when it took effect would produce genuinely retroactive effects. If applying the new provision would produce such retroactive effects, VA ordinarily should not apply the new provision to the claim. If applying the new provision would not produce retroactive effects, VA ordinarily must apply the new provision. VAOPGCPREC 7-2003. In accordance with VAOPGCPREC 7-2003, the Board has reviewed the revised rating criteria for evaluation of mental disorders. The revised rating criteria for evaluation of mental disorders would not produce retroactive effects since the revised provisions affect only entitlement to prospective benefits. It is clear from the provisions of the revised regulations that such regulations are effective from November 7, 1996. Accordingly, the Board finds that VA must apply the new provisions from the effective date of November 7, 1996. Thus, in accordance with VAOPGCPREC 7-2003, the Board will analyze the veteran's claim for higher initial evaluation for PTSD under the former version of the rating criteria for evaluation of mental disorders effective prior to November 7, 1996, the effective date of the amended regulations. The Board will then analyze the veteran's claim under the amended regulations from November 7, 1996. 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 VAOPGCPREC 9-93, 59 Fed. Reg. 4,752 (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 (2004), 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 staged ratings are warranted in this case involving an appeal of the initial disability assigned for the veteran's PTSD. In particular, the Board finds, with resolution of any doubt in favor of the veteran, that the criteria for a schedular 100 percent disability rating are met for the period from April 6, 2004. On that date, the Board of VA psychiatrists determined that the veteran determined that the veteran's PTSD was "severe" resulting in severe impairment in his reliability and flexibility. While difficult to separate the symptoms of his PTSD from his nonservice-connected personality disorder, it was opined at that time that the veteran was unemployable due solely to his PTSD. As the recent findings from the April 2004 VA examination show that total occupation and social impairment due to the veteran's PTSD, a 100 percent disability rating for the from April 6, 2004, is warranted based on the schedular rating currently in effect. However, while the schedular criteria for an increased rating were met from April 6, 2004, the Board finds, following a careful review of the evidence, that the record presents no basis for assigning a rating in excess of 30 percent for PTSD prior to April 6, 2004. The record prior to April 2004 contains numerous pertinent VA examinations. The record for this period 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; multiple VA social and industrial reports; and VA field examination reports. Essentially, the medical evidence prior to April 2004 presents a veteran who has consistently been diagnosed by examining psychiatrists as having PTSD, a personality disorder, a learning disability, and alcohol abuse; however, he is service connected only for PTSD. A thorough review of the record prior to April 2004 shows the extent to which both his learning disability and his longstanding alcohol abuse adversely impacted his development, his relationships with others, and his self-esteem throughout the years, dating back to childhood. Prior to April 2004, the evidence showed that a substantial component of the veteran's over-all psychiatric condition was his personality disorder, which is not a disease within the meaning of the applicable legislation, providing compensation benefits. See 38 C.F.R. §§ 3.303(c), 4.9, 4.127. In this regard, the Board is constrained to observe that the personality disorder and its disabling effects, had persisted since his early childhood. The pre-service medical records document the need for extensive treatment efforts for many years, to include psychotherapy, family counseling and, for a period, use of Dilantin. Contrary to the statements of the veteran's parents to the effect that all his problems began in service, the record is replete with references to adjustment difficulties in childhood and adolescence, a "severe" personality disorder, early estrangement from peers, academic failures, poor self-esteem, conflicts with parents, and a significant history of alcohol abuse beginning at age 13 or 14. It is noteworthy that the veteran, at the time of the entry examination in December 1973, denied having a history of depression or nervous trouble, and failed to report his past psychiatric treatment. Nonetheless his behavior difficulties continued in service, as evidenced by statements from his commanding officers and a military psychiatrist. Their remarks strongly suggest to the Board an ongoing failure to adapt to service, which has been acknowledged by the veteran himself during his examinations. These factors need to be kept in mind when considering the extent to which PTSD alone impaired occupational and social functioning prior to April 2004. The Board recognizes that the veteran has received Social Security disability benefits throughout the course of his appeal; however, the receipt of those disability benefits is based on his overall debilitating condition which consists of a combination of PTSD, a personality disorder, a learning disability, and alcohol abuse. These disability benefits were not awarded on the basis of the severity of the veteran's PTSD alone. Likewise, although the evidence prior to April 2004 contains numerous medical references and opinions noting that the veteran's condition would make it unlikely that he could obtain and maintain meaningful employment, again, those assessments (other than that of the private physician) were made based on the veteran's overall condition and not on the severity of his PTSD alone. The first clinical evidence of record associating the veteran's unemployability solely to his service-connected PTSD is the April 2004 VA examination report. In evaluating the veteran's service-connected PTSD prior to April 2004, it must be remembered that it is the severity of that psychological disorder that is being evaluated, not his personality disorder or alcohol abuse. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The report of the VA psychiatric examination in August 1990 notes that the veteran's overwhelming problem was from his personality disorder which pre-existed his military service. In March 1996, a Board of two VA psychiatrists opined that the veteran's nonservice-connected personality disorder and PTSD equally contributed to psychiatric condition. Similarly, the report of a January 1998 VA examination indicates that the veteran had relatively little symptoms of PTSD, but he continued to manifest many symptoms of a personality disorder. In June 2000, a VA psychiatrist examined the veteran and concluded that the veteran's difficulty with judgment was related to his personality disorder rather than PTSD. It was noted that the veteran lacked the ability to manage his own affairs due to his nonservice-connected personality disorder. The Board notes that these examiners conducted a careful study of the entire record, which reflects a long history of psychiatric impairment that has existed since the veteran's childhood and for which he and his parents underwent extensive pre-service evaluation and treatment. Although the veteran denied pre-service psychological or psychiatric treatment at the time of service entry, the extensive pre- service records clearly contradict his denial of pre-service psychiatric history. 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. Further, the medical opinions prior to April 2004 clearly reflect 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 negative parental influence. Prior to April 2004, the examining psychiatrists, psychologists, and counselors 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. These examiners have further noted that, although the veteran suffered from PTSD, his overwhelming problem was his personality disorder manifested, according to the examining psychiatrists, by feelings of fearfulness, poor interpersonal functions, impaired judgment, and circulatory speech. It was apparent that, although the veteran exhibited many overlapping symptoms, prior to April 2004 the professional medical examiners were able to differentiate, through personal examination of the veteran and review of his medical records, to include the Social Security Administration support medical reports, between his service-connected PTSD and his nonservice-connected personality disorder. These medical opinions consistently expressed by the VA examining psychiatrists and psychologists attribute the veteran's overall disability as a mixture of symptoms of PTSD and personality disorder, with multiple components. Further, these examiners' 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, with learning disability, and alcohol abuse. It is noted that 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 had a major impairment in family relations, work, judgment, and thinking. It is again important to remember that the GAF score was based on the veteran's overall condition, which included PTSD and personality disorder, with learning disability; not on the severity of PTSD alone. 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 examination 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 played 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 suggests serious symptomatology indicative of an inability to obtain and maintain gainful employment. However, in the veteran's case, the overall score included both his service-connected PTSD and a nonservice connected personality disorder, with a learning disability. Prior to April 2004, the medical experts, i.e., psychiatrists and psychologists, were able to differentiate between the two disabilities and have consistently offered that the veteran's primary problem is his personality disorder, although there is some overlapping symptomatology with his PTSD. Because the examiners have distinguished the effects of service- connected PTSD from his nonservice-connected psychiatric conditions, i.e., personality disorder, these "global" GAF scores do not bear on the severity of the veteran's service- connected PTSD. See Mittleider, 11 Vet. App. at 182. In addition, following numerous psychiatric evaluations, the psychiatrists have consistently described the veteran's PTSD as moderate prior to April 2004. On that note, it would be remiss on the part of the Board not to address the January 2002 medical opinion offered from a private physician which, in pertinent part, states that he had reviewed the Board decision file and it was his opinion that the veteran's PTSD caused his severe social and occupational impairment as well as his incapacity to acquire and maintain employment. It is noteworthy that this physician, unlike the VA examiners, is not a psychiatrist or other mental health practitioner, but a specialist in internal medicine. Although the physician related that he reviewed the Board "decision file," it does not appear that he was privy to a copy of the complete claims file. He referenced portions of some VA examination results and noted that the veteran was in a substance abuse program as a result of a DWI arrest. He did not discuss, or even mention, the large volume of medical evidence detailing the existence of pre-service disability and treatment for a severe personality disorder. Further, while the physician makes no mention of personally examining the veteran, it is highly unlikely that he did so in view of the fact that his office is located thousands of miles from the veteran's residence. It is also curious that he makes no reference to the veteran's personality disorder, and obviously no distinction between the veteran's PTSD and his personality disorder, although numerous psychiatrists over the years, based on examination of the record and of the veteran, some psychiatrists on multiple occasions, have offered that the personality disorder is a major disorder in the veteran's overall disability. Furthermore, those psychiatrists have been able to distinguish the symptoms attributable to PTSD and to the personality disorder, although there is some overlapping symptomatology, and to assess the severity of each psychological disorder. Those cumulative factors substantially lessen the probative value of the private doctor's opinion and, as a result, the Board places very little weight upon it. Under the circumstances, the Board finds that the 30 percent rating assigned PTSD from the effective date of the grant of the award to April 6, 2004, is entirely appropriate and comports with the criteria for evaluating psychiatric disabilities. The Board notes that the evidence prior to April 2004 does indicate that the veteran had impaired interpersonal relationships, as noted during his June 2000 VA 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 prior to April 2004. 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 in effect prior to November 7, 1996) 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 in effect from November 7, 1996) 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 prior to April 6, 2004. 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 consideration of an evaluation in excess of 30 percent prior to April 6, 2004, 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 did not take medication nor has he been hospitalized for treatment of a psychiatric disorder. Rather, as noted above, the examining psychiatrists prior to April 6, 2004 consistently found moderate social or occupational impairment due to his PTSD. For all the foregoing reasons, an evaluation in excess of 30 percent for PTSD prior to April 6, 2004 must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, in light of the overwhelming and consistent psychiatrist opinions, based on personal examination of the veteran and review of the record over the many years of this appeal, balanced against the opinion offered by a physician, who specializes in internal medicine and not psychiatric disorders, who based his opinion exclusively on review of some VA examination reports, the Board finds that the preponderance of the evidence is against a higher rating prior to April 6, 2004, and 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 a veteran is competent to receive direct payment of VA benefits is governed by 38 C.F.R. § 3.353(a) (2004), 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). In this regard, the veteran's attorney has argued that the Board, in its earlier determinations, applied the "wrong standard" in making its determination on the issue of competency. The Board does not agree. A finding of competency clearly does not require a preponderance of the evidence; the evidence showing competency need only be at least in equipoise, at which point reasonable doubt is resolved in favor of the claimant. But where the weight of the evidence does not favor a finding of competency, or is not in equipoise, then it may be said that the preponderance of the evidence supports a finding of incompetency. With this in mind, a review of the evidence follows. The veteran has been afforded numerous VA examinations during the course of this appeal, including several conducted by boards of two psychiatrists. Following examination of the veteran and a review of his claims folder in March 1996, a board of two psychiatrists 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. However, the file indicates that the veteran was placed under direct supervised payment. Following VA examination in January 1998 by one of the two physicians who had examined the veteran in March 1996, it was noted by the physician that the issue of competency in this case was an "unusual" one in that in his forty years of practice as a VA psychiatrist, 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. He specifically recommended that the veteran be rated as incompetent for VA purposes. The various VA field examinations indicate that 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 help from his parents. However, as noted in the most recent field examination in September 2003, the veteran, while capable to manage his current income, was not realistic about how he could live within his means. The various psychiatric examinations have consistently shown that the veteran is not competent to handle his VA benefits. 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 previously 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. Similarly, the board of two psychiatrists that examined the veteran in April 2004 concluded that the veteran was not competent to handle his funds. His learning disability was noted to be a contributing factor in this finding. While his parents felt that he could manage his own affairs, they provided evidence that he had trouble with his finances and paying his bills. He had gone through bankruptcy in the past and owned his parents more than $100,000. As noted earlier in this decision, unless the medical evidence is clear, convincing, and leaves no doubt as to the person's incompetency, the RO will make no determination of incompetency without a definite expression regarding the question by the responsible medical authorities. In making the determination, the determination should be based on 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 benefit of the doubt doctrine is a unique standard of proof that applies in decisions on claims for veterans' benefits. Unlike other claimants and litigants in other matters, pursuant to 38 U.S.C.A. § 5107(b), a veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. Also, the benefit of the doubt rule does not shift from the claimant to the VA the initial burden to submit a facially valid claim. When all evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. See Gilbert, 1 Vet. App. at 55-56. In the veteran's case, there are several field examiners who weigh in favor of the veteran's competency and several VA examining psychiatrists who are against such a finding. The field examiners based their opinion on unannounced visits with the veteran at his home without consideration of the veteran's claims folder or medical records. The VA psychiatrists' opinions are based on multiple personal examinations of the veteran, both before and after the field examiners' visits to the veteran, and multiple reviews of the veteran's records, in other words, "based upon all the evidence of record." See 38 C.F.R. § 3.353(c). Significantly, the veteran has offered no psychiatric opinion that he is competent to manage his own affairs. The private physician's statement of January 2002 only mentioned that the veteran had been ruled incompetent. In determining incompetency, there is a presumption in favor of competency, unless a reasonable doubt arises regarding a beneficiary's mental capacity to manage his own affairs. See 38 C.F.R. § 3.353(d). In light of the results of multiple psychiatric examinations, conducted both prior to and after the various field examinations, and the opinions offered by those examining psychiatrists as to the veteran's inability to manage his own affairs, including the disbursement of funds without limitation, the Board finds that the medical evidence is clear, convincing, and leaves no doubt as to the veteran's incompetency. Under the circumstances, the Board finds that the veteran is incompetent for VA purposes. In so deciding, the Board observes that in determining whether evidence is equally balanced such as to entitle a veteran to the benefit of the doubt, equal weight is not accorded to each piece of material contained in the record; every item does not have the same probative value. The Board's determination of what weight to attach to the evidentiary record is more qualitative than quantitative. Further, determinations relative to incompetency are to be based on all evidence of record, see 38 C.F.R. § 3.353(c). Here the Board finds that the medical opinions against the veteran's claim of competency are significantly more persuasive than the veteran's own self-serving assertions and the opinions offered by the field examiners based solely on a one-time home visits with the veteran without the benefit of having reviewed the veteran's medical records and previous psychiatric evaluations. In so stating, the Board emphasizes that the evidence regarding competency does not favor a finding of competency and is not in equipoise; therefore, there is no reasonable doubt on this matter to be resolved in the veteran's favor. That said the preponderance of the evidence clearly militates against a finding of competency. ORDER A 100 percent disability rating for post-traumatic from April 6, 2004, is granted subject to the laws and regulations governing the payment of VA benefits. As the assignment of a 30 percent rating for post-traumatic stress disorder from the grant of service connection to April 6, 2004, was proper, a higher evaluation 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 Department of Veterans Affairs