Citation Nr: 1300187	
Decision Date: 01/03/13    Archive Date: 01/11/13

DOCKET NO.  93-10 552	)	DATE
	)
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On appeal from the
Department of Veterans Affairs Regional Office in St. Louis, Missouri


THE ISSUES

1. Entitlement to an initial rating in excess of 30 percent for a psychiatric disability, to include posttraumatic stress disorder (PTSD).

2. Entitlement to a compensable rating for scars of the head, face, or neck.

3. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU rating).


REPRESENTATION

Appellant represented by:	Mark R. Lippman, Attorney


ATTORNEY FOR THE BOARD

D. M. Casula, Counsel 
INTRODUCTION

The Veteran had active duty from July 1965 to July 1970. 

This matter comes before the Board of Veterans' Appeals (Board) from a February 2008 rating decision of the above Regional Office (RO) of the Department of Veterans Affairs (VA) which granted service connection for a psychiatric disorder, to include PTSD, and assigned a 10 percent rating, effective December 14, 1990.  

In a March 2009 rating decision, the RO granted a 30 percent rating for the service-connected psychiatric disability, to include PTSD, effective January 6, 2009.  

In October 2009, the Board issued a decision which, in pertinent part, granted an earlier effective date of December 3, 1986, for the award of service connection for a psychiatric disorder, to include PTSD, remanded this matter to the RO for further action, to include notifying the Veteran of both the old and new versions of Diagnostic Code (DC) 9411, in effect prior to and from November 7, 1996; scheduling him for a VA examination to determine the severity of his service-connected psychiatric disability, furnishing the VA examiner both the old and new versions of DC 9411, advising the VA examiner to provide findings consistent with those criteria, and readjudicating the claim under both the old and new rating criteria.  A review of the record shows that such actions, as set out in the remand, were accomplished by the RO; thus, the Board is satisfied that there has been substantial compliance with the remand directives set out in October 2009.  Stegall v. West, 11 Vet. App. 268 (1998).

By October 2009 rating decision, in order to effectuate the Board's October 2009 decision, the RO granted an earlier effective date of December 3, 1986, for the grant of service connection for a psychiatric disability, to include PTSD, and assigned a 10 percent rating, effective from December 3, 1986, and continued the 30 percent rating, which had been assigned effective from January 6, 2009.

Received from the Veteran in May 2010 was a notice of disagreement in which he indicated that he disagreed with the October 2009 rating decision for several reasons.  In response to this and other correspondence from the Veteran's representative, by July 2011 rating decision, the RO granted a temporary total rating (TTR), pursuant to 38 C.F.R. § 4.29, for a period of hospitalization over 21 days, for the service-connected psychiatric disability, to include PTSD, effective from December 3, 1986 through March 31, 1987; granted a 30 percent rating effective from April 1, 1987; granted another TTR, pursuant to 38 C.F.R. § 4.29, for a period of hospitalization over 21 days, effective from February 1, 1990, through February 28, 1990; and then continued the 30 percent rating, effective from March 1, 1990.  The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that a rating decision issued subsequent to a notice of disagreement which grants less than the maximum available rating does not "abrogate the pending appeal."  AB v. Brown, 6 Vet. App. 35, 38 (1993).  Consequently, the matter of a higher rating for the service-connected psychiatric disability, to include PTSD, as listed on the front page, remains in appellate status. 

In a letter dated in May 2010, the Veteran claimed that because of his combined disabilities, he should be compensated at 100 percent because he was unemployable.  In Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU rating is part of an increased rating claim when such claim is raised by the record.  See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009).  Thus, in light of the Veteran's contentions, the Board finds that the issue of TDIU is raised by the record and is part and parcel of the increased rating claim, and is properly before the Board.  See Rice v. Shinseki, supra.  It appears that the RO may already be considering a claim for a TDIU rating, as evidenced by the VCAA letter sent in October 2010 regarding that issue.  However, review of the record and the Veteran's Virtual VA efolder does not reveal that a rating decision has been issued.  Thus, the issues are as noted on the title page. 

In addition, in May 2010, the Veteran submitted a letter in which he expressed his disagreement with the June 2009 RO rating decision, which denied a compensable rating for scars of the head, face, or neck.  Although the RO issued another rating decision in August 2012, denying a compensable rating for scars of the head, face, or neck, a review of the claims folder as well as the Veteran's Virtual VA folder shows that a statement of the case (SOC) has yet to be issued on that issue.  Thus, the claim for a compensable rating for scars of the head, face, or neck, must be remanded to the RO, so that an SOC may be issued to the Veteran.  Manlincon v. West, 12 Vet. App. 238 (1999). 

The issues of entitlement to a compensable rating for scars of the head, face, or neck and entitlement to a TDIU rating are addressed in the REMAND portion of the decision below, and are REMANDED to the RO.  VA will notify the Veteran if further action is required on his part.


FINDINGS OF FACT

1. Effective prior to November 7, 1996, the Veteran's psychiatric disability, to include PTSD, was productive of no more than definite social and industrial impairment. 

2. Effective from November 7, 1996, the Veteran's psychiatric disability, to include PTSD, has been productive of no more than definite social and industrial impairment, or, under the revised criteria, his psychiatric disability was productive of occupational and social impairment with occasional decrease in work efficiency, and intermittent periods of inability to perform occupational tasks, although generally functional satisfactorily, due to symptoms such as depressed mood, anxiety, suspiciousness, panic attacks, sleep impairment, and mild memory loss, as well as flashbacks, nightmares, anger.

3. Effective from June 11, 2011 (date of the most recent VA examination), the Veteran's psychiatric disorder, to include PTSD, was manifested by no more than moderate to severe occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking or mood, due to multiple symptoms both listed in the rating criteria, and not listed in the rating criteria; creating a reasonable doubt as to whether a higher disability rating is warranted under the Rating Schedule. 


CONCLUSIONS OF LAW

1. Effective prior to November 7, 1996, the criteria for a rating in excess of 30 percent for a psychiatric disability, to include PTSD, have not been met.  38 U.S.C.A. 1155, 5107 (West 2002); 38 C.F.R. Part 4, 4.132, Code 9411 (1996). 

2. Effective from November 7, 1996 to June 10, 2011, the criteria for a rating in excess of 30 percent for a psychiatric disability, to include PTSD, have not been met.  38 U.S.C.A. 1155, 5107 (West 2002); 38 C.F.R. Part 4, 4.132, Code 9411 (1996); 38 C.F.R. Part 4, 4.130, Code 9411 (2012). 

3.  Giving the benefit of the doubt to the Veteran, effective from June 11, 2011, the criteria for a 70 percent rating for a psychiatric disability, to include PTSD, have been met.  38 U.S.C.A. 1155 (West 2002); 38 C.F.R. Part 4, 4.132, Code 9411 (1996); 38 C.F.R. Part 4, 4.130, Code 9411 (2012). 


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Board has thoroughly reviewed all the evidence in the Veteran's claims folder.  Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000).  The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim.  The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein.  See Timberlake v. Gober, 14 Vet. App. 122 (2000).

I. Duty to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a).

Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide.  38 C.F.R. § 3.159(b)(1), as amended, 73 Fed. Reg. 23,353 (April 30, 2008).  This notice must be provided prior to an initial decision on a claim by the RO.  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). 

The VCAA notice requirements apply to all five elements of a service connection claim:  (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted.  Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006).

If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC).  Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial.  Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006).

The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) previously held that any error in VCAA notice should be presumed prejudicial, and that VA must bear the burden of proving that such an error did not cause harm.  Sanders v. Nicholson, 487 F.3d 881 ( Fed. Cir. 2007).  However, the U.S. Supreme Court (Sup. Ct.) has reversed that decision, finding it unlawful in light of 38 U.S.C.A. § 7261(b)(2).  The Supreme Court held that - except for cases in which VA failed to meet the first requirement of 38 C.F.R. § 3.159(b) by not informing the claimant of the information and evidence necessary to substantiate the claim - the burden of proving harmful error must rest with the party raising the issue, the Federal Circuit's presumption of prejudicial error imposed an unreasonable evidentiary burden upon VA and encouraged abuse of the judicial process, and determinations on the issue of harmless error should be made on a case-by-case basis.  Shinseki v. Sanders, 129 S. Ct. 1696 (2009). 

In a claim for increase, the VCAA requirement is for generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned.   Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009).

In this case, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in November 2003 and in May 2011 that fully addressed the notice elements in this matter.  Since the appellate issue in this respect (entitlement to assignment of an initial compensable rating) is a downstream issue from that of service connection (for which the November 2003 letter was duly sent), another VCAA notice is not required.  VAOPGCPREC 8-2003.  This appeal is from the initial rating assigned with the grant of service connection.  The statutory scheme contemplates that once a decision awarding service connection, disability ratings, and effective dates has been made, statutory notice has served its purpose, and its application is no longer required because the claim has already been substantiated.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006).  The Veteran is exercising his right to appeal the rating assigned.  In addition, in the letter dated in May 2011, the Veteran was advised of the old and current criteria for rating a psychiatric disability.  In addition, in the statement of the case (SOCC) dated in September 2008 and the supplemental statements of the case (SSOCs) dated in March 2009 and October 2001, included an explanation of what the evidence showed and why the current rating was assigned.  The Veteran has had ample opportunity to respond and supplement the record, and, in addition, in July 2012, his motion, requesting additional time to submit evidence in support of his appeal, was granted.  The Veteran is not prejudiced by this process; notably, he does not allege that notice in this case was less than adequate or that he is prejudiced by any notice deficiency.  See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Goodwin v. Peake, 22 Vet. App. 128 (2008).  The Board also notes that in a letter dated in October 2010, the Veteran was advised of how disability ratings and effective dates are assigned.  See Dingess v. Nicholson, supra. He has not demonstrated any error in VCAA notice; thus the presumption of prejudicial error as to such notice does not arise in this case.  See Sanders v. Nicholson, supra.  The Board therefore concludes that all required notice has been given to the Veteran.

The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claim.  VA has obtained all identified and available treatment records for the Veteran.  In addition, the Veteran underwent several VA examinations during the course of the appeal period, including in April 1996, October 1997, November 1998, January 2008, January 2009, and June 2011.  The Board finds that these VA examinations are adequate, and that each examination included a review of the claims folder and a history obtained from the Veteran, and examination findings were reported, along with diagnoses/opinions, which were supported in the record.  See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007).  It appears that all obtainable evidence identified by the Veteran relative to his claim has been obtained and associated with the claims folder, and that neither he nor his representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal.  The Board concludes that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim.  Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, supra.

The Board concludes that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA.  No useful purpose would be served in remanding this matter for yet more development.  Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran.  The United States Court of Appeals for Veterans Claims (Court) has held that such remands are to be avoided.  Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

II. Factual Background

In a letter to a U.S. Senator, dated in November 1986, the Veteran claimed he had several "nervous attacks" in the past, and that in early November 1986, he had another nervous attack and attempted suicide, and was admitted to the hospital to the psychiatric service, and after two days was transferred to the alcoholic program.  He claimed his major problems included a nervous condition, depression, and suicidal tendencies, but asserted that he was receiving little or no treatment for these conditions, and was scheduled to be released in early December 1986

In a letter to a U.S. Senator, dated in March 1987, the Veteran discussed his recent VA hospitalization.  He claimed that the psychiatry service there had been negligent, and that two weeks prior he had acute depression and suicide thoughts following being punished by the treatment team for depressive sleeping during lectures.  He claimed he had numerous unsuccessful attempts to obtain treatment via the nursing team for his hallucinations, nightmares, and depression.  He claimed that on March 5, 1987, he had a meeting with the nursing team and was reportedly issued an ultimatum to be out of the program by March 13, 1987.  

A VA hospital discharge summary showed that the Veteran was hospitalized from November 1986 through March 1987.  His admission diagnoses included dysthymic disorder and his discharge diagnoses included atypical mixed personality disorder.  On admission he reported a history of depression, and reported that he was involved in a motor vehicle accident in 1970 and that was the start of his troubles.  He reported that much of his depression was associated with the fact he could not find continuous employment.  During this hospitalization, the Veteran underwent treatment in the alcohol unit, and also the psychiatry unit.  It was noted that he was not cooperating with his groups sessions and seemed poorly motivated for self-help, and was preoccupied with the need to have further evaluation and service-connected disability for his low back pain.  It was noted that in January 1987, he was transitioned to the psychiatric rehabilitation program, and it was noted that he had been uncooperative and, early in the program, slept through the majority of his group sessions.  It was noted that he had been confronted about his behavior and had become more compliant.  Though he was frequently isolated from other patients and staff, it was noted that he was generally pleasant and had not been a behavior problem.  On discharge it was noted that he was able to work.  

VA treatment records from the Veteran's hospitalization from November 1986 through March 1987, showed that on March 5, 1987, the Veteran complained of increased hallucinations, and when queried, he was extremely vague about these.  The examiner doubted that the Veteran had genuine hallucinations, and the plan was to help him focus on coping effectively and minimizing intrusions of unusual sensory phenomena.  For discharge planning, it was noted that it was very difficult to understand what the Veteran wanted, and he had expressed dissatisfaction with treatment but could not specify what he would have instead.  He did respond positively to the suggestion of job-seeking passes.  At his discharge planning meeting, he finally stated he wanted medication for his medical conditions and a place to stay.  The social worker agreed to help him find gainful employment and available community halfway houses.  The assessment was that the Veteran's behaviors, interpersonally, seemed oppositional and adversarial and suggestive of paranoid tendencies.  However, it was also noted that he did not request psychiatric treatment.  The social worker noted that his behaviors could also be seen as goal-oriented and manipulations finally aimed at the Veteran's need for room and board.  On March 13, 1987, it was noted that the Veteran was discharged in stable condition and he had been taking passes all that week looking for a job.  He stated that the prospects were good and he had a place to stay, but did not elaborate.  He was in the program for approximately six weeks and the first month he attended most of his groups, but slept the whole time.  When he was approached and told he would be discharged if he did not start participating, he stated he was sleeping because of his medication, and later stated it was because of depression.  The social worker noted that the Veteran was seen in team meetings because of his lack of participation, and he could not tell what he was getting out of the program or what he wanted, except a place to stay while he got a job.  He was advised that this was not the purpose of the program and he was given a week to find a job and a place to live, and the social worker offered to help the Veteran.  

In a statement dated in November 1987, the Veteran reported he was having "extreme difficulty in holding down a job primarily due to [his] back, hips, and knee conditions" and claimed that the limitations resulting from these conditions hampered his ability to maintain employment.  

A VA hospital medical record shows that in June 1988, the Veteran presented with complaints of feeling depressed, suicidal, and lots of pain, and he was requesting medication.  He was hospitalized for one night, secondary to suicidal ideation.  He reported that since his prior discharge, he had a history of repeated alcohol abuse/dependence and cannabis abuse.  On the admission note, it was revealed that the Veteran presented with a chief complaint of wanting to commit suicide, feeling depressed, and in pain due to an old hip and back injury.  He admitted that he planned to kill himself by taking an overdose of pills.  He reported he ran out of his prescription medications over one month prior - including pain medications, Elavil, and muscle relaxants.  He reported that two weeks prior he started to feel more depressed, started drinking more alcohol than usual, and was using marijuana again.  He reported decreased sleep and appetite, that he had a couple of blackouts, and that his mind was "not functioning right".  He denied hearing voices, but admitted to paranoid delusions of people following him.  On mental status examination at admission, he seemed depressed but was able to look interested in his surroundings.  After being admitted, on mental status examination he was alert and oriented, his mood was euthymic, and he denied suicidal thoughts or homicidal ideation.  He was evasive to questions, and there was no evidence of thought disorder.  On discharge, it was noted that he was able to return to work and competent to handle funds.  He was offered a consultation or following, but insisted on leaving hospital that day.  The discharge diagnoses included continuous alcohol and cannabis abuse.  

A VA hospital summary showed that the Veteran was hospitalized in February 1990, for approximately a month, after being seen in the emergency room for back pain and a depressed mood.  He reported suicidal ideation with no plans for two nights prior to admission.  He also noted decreased sleep, decreased appetite, and depressed mood.  He denied delusions and hallucinations at that time.  He reported a past history of violent behavior and periods of rage, and did impulsive acts.  He reported he lived alone, was separated, and had one son from his first marriage that he had not seen in years.  On mental status examination, he made eye contact and had normal psychomotor activity.  His speech was of regular rate and rhythm, and he denied current auditory hallucinations.  He had some visual hallucinations in the past, but none at the present since he was off alcohol.  He had feelings of helplessness and guilt and denied homicidal ideations.  His mood and affect were depressed and dysphoric, and his concentration, insight and judgment were fair to poor.  He verbalized he would contact staff if suicidal ideation persisted or if an attempt was to be made.  During the hospital course, the Veteran was preoccupied with thought of hopelessness and suicidal ideation in regard to past events that had occurred in his life, and his depressed mood continued.  He was placed on medication, and continued to be isolative, but cooperative in attending activities.  It was noted that he showed an interest, was helpful on the unit, and started making goals.  His suicidal ideations resolved, his sleep and appetite improved, and overall his depressed mood slowly decreased.  On examination at discharge he denied suicidal and homicidal ideation, denied hallucinations and delusions, and had a good mood and affect, and improved concentration.  With regard to medications and prior suicidal ideation, he reported he was doing much better and was safe.  

The day after his discharge, in February 1990, the Veteran was reportedly scheduled for admission to the domiciliary.  He voiced no complaints, denied suicidal thoughts, and had no hallucinations or delusions.  On examination he was found to be oriented, and the diagnoses included atypical major depression.  In early March 1990, he reported he wanted to reintegrate into a normal life in the community after being hospitalized for depression.  Of late he had developed a closer relationship with his mother, but did not tell her his problems.  His sister wanted him to get well, but knew he was an "independent person".  He reported liking computers, crossword puzzles, and helping other people.  He used to collect coins and enjoyed studying history and science.  The social work assessment was that he tended to ramble, tried to be explicit, and had trouble focusing and tracking.  It was noted that he would need follow up at the mental health clinic.  He was to work toward obtaining and maintaining employment, and community integration.  

Records dated in March 1990 showed that the Veteran was seen in the mental health clinic.  Although the writing is most illegible, it appears that he reported a history of depression, and on examination he was found to be alert and oriented with a dull affect.  There is notation of hallucinations.  It was also noted that he was at times vague and evasive.  He felt better on his medications, and the impressions included history of atypical depression.  A week later his diagnosis was listed as atypical major depression, and rule out dependent personality.  On mental status examination he was alert and oriented and his mood was euthymic.  He made poor eye contact and had tangential and circumstantial responses.  He denied suicidal and homicidal thoughts.  In mid-March 1990, a psychology note indicated that the Veteran had an irregular work history and had been employed primarily through temporary agencies for the last 10 years.  His long term goal was to get further training and a BS degree in computer programming.  He was to be evaluated for 30 days before exploring vocational rehabilitation training.  

VA treatment records show that in May 1990, the Veteran had attended five group sessions of the depression group.  It was noted that he was quiet in the initial sessions due to physical discomfort, but had participated actively lately and was planning for his future and for work.  He needed further work in understanding and practicing cognitive techniques for dealing with depression.  His activity level appeared to be good.  It was noted that the Veteran remained open to the depression group.  Further, in May 1990 and June 1990, it was noted that he continued to actively look for work.  In June 1990, it was noted he had missed three groups sessions, but attended the last two, his participation had increased, and he spent less time with his eyes closed due to dental and back pains.  At the most recent group session, he was noted to be out of character and was complaining about how VA was dealing with him and his health problems.  The social worker noted that although there may have been some basis for his complaints, he appeared to have paranoia, as he expressed that the VA staff was out to get him.  In early July 1990, the mental health clinic issued a closing summary for the Veteran.  Therein it was noted that his problems were emotional and behavioral and that he had attended 11 of 15 depression groups.  He was quiet much of the time, and appeared to nod off, but claimed he was having a problem with pain and had listened.  He appeared at times to have paranoid negative thinking, and it was hard for him to see his own cognitive traps or distortions that added to his anger and depression.  He verbalized feeling the group had been helpful to him.  In July 1990, it was noted that the group was being suspended and the Veteran regretted this.  He had participated in the recent sessions and asked to be put on the waiting list for the next depression group.  The outcome for the Veteran was noted to be "problem treated improved".

Thereafter, in July 1990, the Veteran was hospitalized for back pain, and at that time he reported that his past medical history included nerve problems.  He reported he had depression off and on since 1968, and that he worried a lot about everything, but was not really feeling depressed now.  It was noted that he lived in the domiciliary and was trying to get back into the community.  On mental status examination, he had a flat affect.  

On a VA examination in August 1990, the Veteran reported he had increased nervous anxiety associated with social maladaptive disorder, but at that time, his nervous system was apparently not evaluated.  

VA treatment records showed that in October 1990, the Veteran reported having frequent nightmares.  On mental status examination, he was found to be alert and oriented and his affect and mood were euthymic.  He denied suicidal and homicidal ideation.  A November 1990 psychiatry note revealed that he was seen for complaints of recurrent nightmares of a previous vehicular accident in the 1970s,  He wanted to be referred for the Topeka VAMC PTSD program.  Later in November 1990, it was noted that the Veteran continued to work temporary employment through a temporary service.  He was attending an anger group and a PTSD group because of his auto accident in service.  He was anxious to attend vocational rehabilitation and wanted training in computer programming.  He was to be assessed for eligibility.  It was noted that the Veteran had received all the benefits available from the "HVP" (Homeless Veterans Program) and was to be transferred to the RC Dom (residential domiciliary) to continue his medical follow up and training.  In December 1990, he was transferred for longer term care needs, and he desired treatment for PTSD and depression, vocational rehabilitation, and medical concerns.  It was noted that he was an outpatient in the mental health clinic and attended PTSD and depression group therapy sessions.  

VA treatment records showed that in February 1991, it was noted that the Veteran had a history of dysthymic disorder related to chronic pain and a history of major depression, as well has a history (per the Veteran) of PTSD.  He reported he had recurrent nightmares of the accident in service, and that his medication helped him sleep, but did not help with the nightmares.  His mood was noted to be "up and down" and his affect was euthymic.  His insight and judgment were slightly good, and the impressions included dysthymic disorder and possible PTSD.  In March 1991, he had a one on one therapy session, and reported he was tired, confused, and thinking unclearly.  He reported there were interviews set up with occupational treatment personnel, but he was recently denied more computer training.  He desired to learn and correct the problems he experienced.  He also reported having flashbacks.  He had a tendency to externalize and blame others, as well as to exhibit paranoid behavior by reacting to conflicts by following the person or watching and investigating them.  He claimed he read people's minds better when he was not emotional.  The examiner noted that the Veteran did not understand the harm in reading minds or following others, and hoped to work with the Veteran on this.  

On VA examination in March 1991, the Veteran reported he had not worked since February 1990, due to physical disabilities, mental stress, and lack of continuous employment.  He continued to suffer from mental and post-traumatic stress, nightmares, pain and limited movement in back, hip, and knees, headaches, loss of memory, loss of sleep, fatigue, blurred vision, and difficulties in coping with daily life.  He reported he had been living at the Leavenworth VAMC domiciliary for the past year.  He had lost a lot of jobs, and rambled a great deal about various jobs he had not held for very long.  He thought he last worked in 1989.  His symptoms of PTSD included daily flashbacks and nightly nightmares about the accident in service.  On mental status examination he was noted to have a clean appearance, but he was difficult to interview because he sat with his eyes shut and talked in a low voice.  He had trouble remembering things and gave rambling answers, and the examiner was not sure if the Veteran was being uncooperative or if this was his normal style.  The examiner noted that although the Veteran appeared oriented, his affect was flat, judgment was questionable, and insight was fair.  His peer relationships were variable, and his temper was short.  He complained of poor sleep and regular nightmares.  His memory and concentration were poor, and his energy was diminished.  He felt depressed, but denied crying spells or suicidal ideation.  He had mild mood swings, and talked in a vague, rambling manner, such that it was difficult to pin him down.  He occasionally felt paranoid, but could not elaborate on this.  He feared having another accident.  He talked about occasional guilt, but did not specify.  He was angry at the military and blamed it for destroying his marriage.  

Further, on the VA examination in March 1991, the examiner noted that he saw the Veteran in the hall after the examination - walking around, with his eyes open, and he seemed much more alert.  The diagnosis was probable PTSD.  The examiner indicated he would like to review the Veteran's records from Leavenworth and any psychological testing, before definitively making a diagnosis, but noted that PTSD was the Veteran's diagnosis in the hospital there and that they could probably back up the diagnosis with clinical documentation.  The examiner noted that the Veteran's symptoms were certainly suggestive of PTSD, including daily flashbacks and nightly nightmares, and he seemed to keep to himself and be withdrawn and depersonalized.  He was anxious and also had some depressions associated with this.  His prognosis was guarded.  The examiner opined that the Veteran's incapacity was "marked", regardless of his diagnosis at the present time.  The examiner noted that the Veteran was living in the sheltered setting of the Leavenworth domiciliary, was in rather intensive care there, and needed to continue with this.  The examiner concluded that based on seeing the Veteran that day, his diagnosis was PTSD with depression and anxiety, but that if PTSD was not the diagnosis the second possible diagnosis would be acute anxiety.  

VA treatment records showed that in early April 1991, the Veteran reported he was doing good, but was tired and energetic.  He reported frustration with his job search because he was not hearing from his applications and he was having difficulties finding a position that met his physical handicaps.  He reported his long term goal was to change or reprogram his entire self and situation.  In the short term, he wanted to find a job.  In the long term, he wanted to stop thinking and self-examining how things were handled and what occurred regarding his service.  This was the first time the Veteran had stated a desire to reduce his focusing on the past and handle current issues better.  Later, in April 1991, the Veteran reported he was still having nightmares, but his sleep was good.  He was looking for work and was involved in a PTSD group and one on one therapy.  On mental status examination, he was alert, oriented, and cooperative, with normal psychomotor behavior, and he had a euthymic affect.  His speech was normal and his thoughts were goal-directed.  He denied suicidal and homicidal ideation, and hallucinations and delusions.  The diagnoses included major depression - treated, and PTSD mild signs and symptoms (nightmares).  In May 1991, it was noted that the Veteran continued to have depression with anxiety, headaches, and PTSD.  He had applied for disability for his mental condition.  Objective examination showed he seemed mildly depressed.  

VA treatment records showed that in July 1991, the Veteran was seen in the mental health clinic and reported an increase in his flashbacks of an motor vehicle accident he was in 23 years prior, in service.  He reported that the symptoms of nightmares and flashbacks of the accident had increased in the last few weeks, and that his one on one therapy helped greatly in the past, but he had not had this since the therapist left in May 1991.  His appetite was fair and he had poor sleep.  Mental status examination showed he was well groomed, and had a fair mood and affect, with a mildly dysphoric affect.  He denied suicidal/homicidal ideation and hallucinations and delusions.  He had paranoia when riding in a car.  Approximately 10 days later, he was seen for follow up in the mental health clinic and reported he was feeling much better since his last visit and had less nightmares and flashbacks.  The impression was that his PTSD had improved and major depression was stable.  In October 1991, he had an appropriate mood and affect, and interacted well.  He was still having periods of depression, and was tired at times.  He denied suicidal thoughts.  He had nightmares and periods of nervousness and anxiety.  The assessment was major depression, some improvement.  In a December 1991 entry, it was noted that the Veteran had attended the last six PTSD group sessions, and he had become gradually more involved, more alert, listening, and responsiveness.  

VA treatment record showed that in January 1992, the Veteran reported flashbacks and nightmares related to the car accident in service.  He reported he was unable to do most kinds of work because of his bad back.  He admitted to periods of depression but denied suicidal or homicidal ideation.  There were no symptoms of psychosis.  The impressions included PTSD and depression.  Later in January 1992, it was noted that the Veteran attended his PTSD group regularly and that his affect and participation varied widely.  In February 1992, he reported he had a temporary job, had an application to be submitted for the Topeka PTSD program, and was going to job service weekly.  A PTSD group note from February 1992 indicated that he had attended regularly during the past month, and had been more alert and involved than in the past months.  He entered discussions readily, whereas in the past he had often been drowsy and uninvolved.  He shared with the group that he tended to sleep when he was depressed, and believed that the group had helped him become less depressed and less of a loner.  He expressed a desire to determine some kind of vocational direction for his future, and stated an interest in attending the inpatient PTSD program in Topeka and he also indicated he wanted to begin one on one therapy.  In March 1992, at an individual therapy session, he had concerns with anger, expressions of hostility, and flashbacks.  He attended a PTSD group which helped him with coping strategies, but he experienced difficulties opening up to a large group.  He did not look directly at the therapist during much of the session and often had his eyes closed while discussing his anger.  In May 1992, his mood was dysphoric and he displayed a limited range of affect.  He referred to flashbacks, but the therapist found these incidents were more memories of past failures than actual flashback episodes.  He continued to complain about memory difficulties.  

VA treatment records showed that in June 1992, the Veteran's mood was euthymic, and there was a discussion about his paranoia.  He denied suicidal and homicidal ideation, his thoughts were goal directed, and there were no signs of psychosis, but he complained of nightmares and flashbacks.  A vocational rehabilitation counseling note from June 1992 showed that the Veteran was seen to update his rehabilitation plan, and it was noted that he had been in search of employment but had several medical issues going on.  His complaints were listed as including:  blackouts since 1983-1984, memory problems, PTSD, wrist problems from a fall three to four months prior, and back and knee problems.  The assessment was that the status of his placement seemed inappropriate due to his multiple physical issues.  In July 1992, during a therapy session, it was noted that the Veteran's tendency to exaggerate symptoms was confronted.  He reported that this, along with his rigid and slow problem solving strategies, had caused him difficulties with employment.  

Records from the Social Security Administration (SSA) showed that in June 1992, the Veteran reported having depression and flashbacks.  On a mental status examination conducted in June 1992, he reported he had been married and divorced twice and had a 22 year old son who he had been looking for years.  He had a hard time getting and keeping regular employment.  He claimed his best job was for a temporary job service in 1988-1989, but reported that the service eventually stopped sending him out on jobs because of his physical handicap, which he described as chronic back pain.  He attended individual and group therapy to help with his PTSD, depression, and coping skills.  He disagreed with psychiatrists who considered him to have a personality disorder, and viewed his problems as pain and depression.  He reported having stress, nightmares, blackouts, and memory problems, and that he was scared to drive.  He reported strange feelings of somebody watching or following him.  On mental status examination, he was apprehensive, anxious, and distant, and appeared clinically depressed.  He eventually become more relaxed and animated, but his affect remained moderately flat.  He had been much more depressed until recently, with intermittent suicidal ideation, which he could not quickly eliminate by talking to someone he knows in his groups at the VAMC.  His remote memory, judgment, and insight were poor.  He showed little capacity for abstract thought, and his thought processes were found to be clouded and mildly confused.  No psychotic thought processes were observed, but he reported having frequently experienced paranoid ideation in the past.  Hallucinations were denied.  He had adjusted well to the structure of the VA domiciliary, and stated a desire to get along with others, but acknowledged a continuing tendency to isolate himself and to have the feeling that he is being watched or followed.  He reported having friends and acquaintances in the domiciliary, but still tended to isolate, but not to the extent he did in the past.  His avoidance problem restricted his daily activities, to a minor extent in a structured setting such as the domiciliary, however, when residing on his own in the community, his social functioning would be expected to quickly deteriorate.  It was noted that there had been repeated episodes of such deterioration in the his social and work situations in the past.  The examiner further noted that this deterioration could be expected to profoundly decrease the Veteran's ability to concentrate, pace himself, and persist in the tasks assigned to him.  The impressions were depressive disorder and dependent personality disorder.  The examiner noted that while there was evidence of an underlying thought disorder in the Veteran, he was not blatantly psychotic.  He could be expected to experience considerable difficulty in maintaining adequate relationships with co-workers and supervisors.  The examiner further noted that although the Veteran was capable of understanding and following simple instructions, this ability diminished under conditions of stress and a reduction in structure.  It was also noted that he found it increasingly difficult to sustain his concentration over the course of an eight hour day even in routine activities.  The examiner opined that the Veteran was not capable of keeping a work schedule with average performance demands.  The examiner also opined that the Veteran's competency tended to deteriorate when he was out on his own in the community, outside of an institutional setting.  

SSA records further show that in July 1992, the Veteran underwent a psychiatric evaluation.  At that time, the examiner checked boxes to indicate that the Veteran had a depressive syndrome characterized by decreased energy, difficulty concentrating or thinking, thoughts of suicide, and paranoid thinking.  With regard to a personality disorder, the examiner checked off that the Veteran had inflexible and maladaptive personality traits, reflected by oddities of thought, perception, speech, and behavior; persistent disturbances of mood or affect; and pathological dependence, passivity, or aggressiveness.  The Veteran was noted to have moderate functional limitations.  In a assessment dated in July 1992, it was noted that the Veteran was functioning at a minimal level, but the team was not sure why.  It was noted that when the Veteran attended group therapy, he tended to get confused.  It was also noted that they were unable to get consistent and valid results from psychological testing and were not sure why.  The Veteran's performance was described as extremely poor, and he was very slow in response to questions and tended to become confused.  They were not suggesting that the Veteran was malingering, but they had no idea why his behavior was the way it was.  The doctor suggested this might be a combination of organicity and possible depression.  

In a statement submitted in September 1992, along with a substantive appeal (VA Form 9), the Veteran claimed he often felt depressed, hopeless, occasionally suicidal, and felt that somehow he could have done something different that would have changed the occurrence or outcome of his major accident or would have prevented it from happening.  He complained of severe problems in coping with everyday problems, demands, and society.  

VA treatment records showed that in March 1993, the Veteran was seen in the mental health clinic and reported he had not been doing well lately.  He felt anger, had pain, and had suicidal ideation but no plan.  He reported having flashbacks and nightmares.  On examination he was alert and his thoughts were goal directed.  He was seen again later in March 1993, and reported feeling better than his last visit, and reported that arthritis interfered with his sleep.  In July 1993, he complained of a poor memory, restless sleep, poor appetite, and having some depression.  His mental status examination at that time was unremarkable.  In October 1993, he reported occasional nightmares, paranoia, and some tactile hallucinations.  In April 1994, he reported getting an adequate amount of sleep, and his appetite was okay.  He denied mood disturbances, and denied homicidal and suicidal ideation.  In June 1994, he reported getting an adequate amount of sleep, and did his own cooking and ate "okay".  He denied hallucinations, delusions, and paranoia.  In October 1994, he was doing well on his medications, but reported having flashbacks if he did not take his medications.  He also reported having tactile and auditory hallucinations, but his mental status examination was unremarkable, and he denied suicidal and homicidal ideation.  In February 1995, he reported a tendency toward anxiety, but indicated that was usually helped with medication.   

VA treatment records showed that the Veteran continued to have periodic therapy in the mental health clinic.  In August 1995 he was seen for follow up, and reported he still had nightmares, but his PTSD symptoms were improved on his current medication.  On mental status examination he was well groomed, had a blunted affect, and denied suicidal and homicidal ideation.   

On the VA examination in April 1996, the Veteran reported his last employment was in 1991 when he worked as a laborer.  He had service-related nightmares and flashbacks.  On mental status examination, he was found to be calm, alert, pleasant, cooperative, and responding to questions in a logical and goal-directed manner.  He had poor organization of his account of his in-service experiences, but denied hallucinations or delusions, and had no suicidal or homicidal ideation.  He had average intelligence, and his memory and judgment were intact.  He had some insight and was motivated to remain productive.  The diagnoses included major depressive disorder and dependent personality.  It was noted that the diagnostic criteria for PTSD were not satisfied, and that the stressors claimed were not of sufficient magnitude and severity to match the alleged symptoms.  A Global Assessment of Functioning (GAF) score of 60 was assigned.  The prognosis was noted to be good in that the Veteran had been able to maintain functional capacity and had not required hospitalization or close outpatient follow-up, and had been able to maintain adequate social function.  His incapacity was assessed as mild.  

VA treatment records showed that in October 1996, the Veteran reported he still had periods of nightmares.  His mood was stable and he had a flat affect.  

On a VA examination in October 1997, the Veteran reported he had held numerous temporary jobs since 1970, but had never lasted long at work and he had reportedly been fired frequently.  He had been told he talked to himself at work and acted in strange ways and would get dismissed.  He reported being married and divorced twice, and had two children whom he never sees.  He currently lived alone and kept to himself, and handled all of his activities of daily living.  He reported living at the Leavenworth VA Medical Center from 1990 to 1992 because of mental and physical problems.  The examiner noted that the Veteran's extensive outpatient treatment records from Leavenworth VA Medical Center indicated that he was treated there for PTSD and depression, and that he was dealing with anger control, nightmares, and flashbacks.  On mental status examination he was found to be clean in appearance and oriented times three.  His affect was tense and somewhat flat, his insight and judgment were fair, and his peer relationships were poor.  He isolated himself, his temper was irritable, and he had sleep disturbances.  He had frequent recurring nightmares, and his memory and concentration were poor.  His energy was low but variable at times, and he said he was depressed to some degree all the time and hid his crying spells from others.  He indicated he did do light housework.  He denied current suicidal ideation and his moods were variable.  It was questionable as to whether he had auditory hallucinations in the past.  He was paranoid frequently, and did not trust people.  He had much anger at people and felt that people had harassed him in the past and had run over him.  His hobby was listening to music, and he claimed he had no social life.  He spent his day trying to do light exercise and light housework, and listening to music.  The examiner indicated that the Veteran met the criteria for PTSD, noting that he had nightmares, flashbacks, middle sleep disturbance, avoidance behaviors, and diminished interest in significant activities.  The examiner also noted that the Veteran felt detached and estranged from others, manifested a restricted range of effect, was hypervigilant, had trouble concentrating, had memory problems.  The diagnoses included PTSD and chronic major depression, and a Global Assessment of Functioning (GAF) score of 50 was assigned.  The examiner indicated that the Veteran's prognosis was poor, his incapacity was marked, he needed to continue with his medications and therapy, he was incapable of persisting at simple tasks, he had problems with interpersonal relationships, he isolates, and he does not get along with people.  

VA treatment records showed that from 1997 through 2000, the Veteran was attending a group therapy for Vietnam survivors.  In January 1998, he was seen for follow up and he was noted to be doing okay and was friendly and pleasant, with excellent grooming.  In April 1998, he reported he was doing well until a few days ago when he started having trouble with his sleeping pattern.  His mood fluctuated to highs and lows, but it had been better that in the past.  He had difficulty admitting that he might be improving, and reported he got irritable around people.  In July 1998, he reported being angry a lot, but was not having many nightmares, and his energy level was down.  He claimed his thoughts were confused at night.  In October 1998, he was found to not being doing well.  It was noted that he was working with vocational rehabilitation, but that he was homeless and had been sleeping in his car.  He had not gotten more than two hours of sleep at a time, and was very tired.  His speech was rambling and he seemed overwhelmed with nowhere to go.  

On a report of private psychological evaluation conducted by Dr. Keith Allen in November 1998, it was noted that the Veteran indicated he wanted help in getting a job and needed retraining because he was used to doing factory work, but could not do the "heavy stuff" anymore.  He reported he had never had a job for over one year since 1973, and had been fired several times for "being to detailed".  He reported he had no contact with his two children.  He claimed he had been diagnosed with bipolar illness due to hallucinations and isolating himself.  He claimed he was going to make the Coast Guard his career, but since getting out he has not been able to find himself.  He reported having nightmares and anger related to his accident in service, and indicated that he had flashbacks.  He was on an anti-hallucinatory medication, and two other medications, and reported that these medications helped him with his blackouts, but that he still had flashbacks.  On the psychological consultation, it was noted that it was difficult to get information from the Veteran because of his presentation style, which was characterized by tangential and circumstantial presentation of information and the need to be brought back to the topic at hand frequently.  He gave repeated stories of how others have picked on him and treated him unfairly, and claimed he had been misunderstood and treated with prejudice.  Dr. Allen indicated that there were no signs of mental confusion or loss of reality contact, and there were no noted uncontrollable or manageable behaviors, and no indications of psychotic thinking.  The Veteran reported he spent his day sleeping, exercising, doing household chores, watching television, listening to music, talking on the telephone, and doing odd jobs.  When asked if he was a depressed person, he responded that he got "pretty angry" due to having a lack of a good occupation and a belief he should have accomplished more.  He denied crying spells presently, and denied feeling anxious or nervous, though he was thorough and meticulous in getting work done.  His appetite was adequate, but he had trouble getting to sleep and staying asleep because of his pain.  He denied suicidal ideations currently, and also denied feeling helpless, hopeless, or worthless.  He had occasional friends and acquaintances that he did things with, but tried to do things on his own because his friends were too busy.  He reported he liked to listen to music, watch sports, and cook.  

Further, in the November 1998 psychological evaluation, Dr. Allen indicated that the Veteran's presentation gave a strong sense of having been mistreated and unfairly treated throughout his life resulting in his not being able to accomplish what he thought he should in life.  The examiner indicated that the Veteran's responses on the MMPI suggested significant anxiety and depression, though he denied depression per se.  The examiner also indicated that his responses indicated that there was likely an underlying depression related to his feelings of failures in his life and that he reported a history of bipolar illness.  The examiner noted that the Veteran reported a history of job difficulties because of what he described as being meticulous, but upon observation and clarification it appeared to the examiner be because of his slow style in performing.  The examiner indicated that the Veteran would likely have a great deal of difficulty on any task that required average or better speed.  The examiner indicated that a release from the Veteran's treating source should be obtained before offering services to ensure that he is able to emotionally withstand any additional stressors that would be offered by job training and/or placement.  The examiner also indicated that the Veteran would be a good candidate for rehabilitative services, but appeared to need a good deal of support in making realistic vocational plans and in carrying out his plans.  The diagnoses included bipolar disorder by history, PTSD, and personality disorder with paranoid personality traits.  A GAF score of 50 was assigned.  

VA treatment records showed that in April 1999, the Veteran was seen for his prolonged PTSD.  He was pleasant and cooperative, and had been busy with going to school.  He had been working with vocational rehabilitation and going to community college, but was having difficulty.  His symptoms were under control, and he felt he was accomplishing his goal and would eventually have a better life.  

In a private treatment record from Kansas University Medical Center, dated in July 1999, it was noted that the Veteran reported having occasional bad dreams related to traumas, but denied depression.  

VA treatment records showed that in October 2000, the Veteran was found to be in a bright mood.  He claimed he was still at school and would be finishing in the Spring, but had been feeling depressed at times.  He claimed he did not want further medication changes, but just wanted someone to talk to.  He reported occasional nightmares, but he was otherwise feeling alright.  In October 2001, he was seen in a slightly anxious mood, but otherwise felt alright.  He was getting nervous at the ongoing world situation, and when he got paranoid he stayed at home.  He had occasional flashbacks, but not as bad as before.  He indicated he was just trying to play music and study for the national examination he was to take.  He denied hallucinations and delusions, and no significant mental status change was noted.  

VA treatment records showed that in March 2002, the Veteran was seen in psychiatry and was noted to have a bright mood and affect.  He had passed the national examination, but was still jobless and did not know why.  He was not trying to avoid crowded places, and had not expressed concerns about the world situation as he had on his last visit.  He still had occasional flashbacks and nightmares of the war.  

In a September 2002 Report of Contact with Dr. Lisandra, included with the Veteran's Social Security Administration (SSA) records, it was noted that the Veteran, at times, became paranoid and upset with the world situation, and would then stay home for a few days.  It was noted that he had PTSD, but was not overly psychotic, was alert and cooperative, with goal-directed speech, and denial of hallucinations and delusions.  He was cognitively intact, and had been able to finish activities involved in school.  Dr. Lisandra indicated it would be difficult to know exactly how the Veteran would function in a work setting, but indicated he should be able to adequately persist on tasks.  Also, Dr. Lisandra indicated that the Veteran could probably socially function adequately in a low demand setting, and that he had significant physical problems that could hinder his capabilities.

On a VA examination in January 2008, the Veteran reported having nightmares and flashbacks since the car accident in 1970 in service.  He feared driving due to the flashbacks and would isolate himself, but indicated he could manage his fear.  His medications were helping him with flashbacks and anxiety.  It was noted that he was unemployed and had been on Social Security disability.  He denied any significant time lost from work, when he was working, due to his nightmares or flashbacks.  He reported he received his bachelor's degree in computer science in 1994.  For leisure activities he liked to study books and work with his computer.  He did not have many social activities because he liked to stay alone, and claimed he did not have friends.  He was able to take care of his himself and his activities of daily living.  On mental status examination, he was alert, oriented, and cooperative, and maintained good eye contact, had good personal hygiene, and dressed appropriately.  He had no signs of inappropriate behavior and he responded in a logical manner.  There were no signs of obsessive or ritualistic behavior, and he showed good impulse control.  His speech pattern were normal and clear, and there was no impairment in his thought process or communication.  He denied delusions, hallucinations, suicidality, homicidality, and was noted to have no memory loss, no history of panic attacks, and no depression or anxious mood.  With regard to his occupational dysfunction, it was noted that he had SSDI since 2001, was able to complete his graduation in computer science, and has worked as a computer operator and other stable jobs.  With regard to social dysfunction, it was noted that the Veteran had intermittent periods of inability to perform occupational tasks due to nightmares and flashbacks, but generally satisfactorily functioning.  The examiner opined that there was intermittent social dysfunction secondary to the above symptoms, and that the Veteran's symptoms are not severe enough to interfere with occupational and social functioning.  The diagnoses included PTSD, chronic, delayed onset; major depressive disorder, recurrent, partial remission; and personality disorder.  A GAF score of 65 was assigned.  

On VA examination in January 2009, the Veteran reported problems with social isolation and generally only leaving the house to grocery shop or attend medical appointments.  He attended a college class once a week.  He felt that others were out to cause him harm and at times he blocked his doors and/or taped them up to keep others out.  It was noted that the Veteran was currently pursuing a health care management master's degree on a part time basis, and had plans to graduate in May 2009.  He maintained a B average at school, and had some problems with concentration.  He stayed to himself at school and did not socialize with other students during breaks.  He reported he avoided class at times due to anxiety and paranoid ideation.  He reported a history of being fired from jobs in the past due to "personality conflicts", verbal altercations, and problems with authority figures.  He reported having a sister and nieces and nephews nearby, but he was not close to any of them, and a daughter who lived out of state, who he maintained occasional phone contact.  With regard to social functioning, it was noted that the Veteran had no close friends and generally spent all of his time alone.  He had recently been homeless, but was currently living in a house he purchased in 2008.  His activities and leisure pursuits were listed as computer activities and studying for school.  His impulse control was okay, he denied suicide attempt since his last evaluation, but indicated he experienced suicidal ideation with a plan to overdose, but he denied any current intention to harm himself.  

Further, in January 2009, on the VA mental status examination, he was alert, oriented, and cooperative, and maintained good eye contact.  His speech was normal and clear, and his thought process tended towards circumstantiality.  His thought content was without hallucinations or suicidal or homicide ideation.  He presented with a "real good" mood and a restricted range of affect.  It was noted that he responded during the session in a logical manner, and had no inappropriate behavior.  He believed others were out to get him, and at times he barricaded himself in his home in order to keep others out.  His maintenance of his personal hygiene and activities of daily living was okay.  With regard to short term memory, he reported having difficulty maintaining his train of thought when talking with someone or when speaking in class.  He worried quite a bit, especially about his family and financial strain.  He experienced anxiety on a daily basis and generally did not leave his home except for appointments or grocery shopping.  He experienced a mild depressed mood on a regular basis, and felt that others did not care about him.  He did not experience panic attacks.  His impulse control was okay.  It was noted that his sleep varied widely, and that at he was often tired and socially isolated during the day.  The examiner summarized that the Veteran's social functioning was impacted by his PTSD symptoms including social isolation, depression, anxiety ,and paranoia, impoverished and/or lack of social relationships, and problems with memory and concentration.  His occupational functioning was impacted by problems getting along with his supervisors and bosses.  He also experienced occasional problems at work due to traumatic memories.  It was noted that he had a high level of educational achievement, but did experience problems with concentration that prolonged his study time.  He also had avoided class at times due to anxiety and paranoid ideation.   His nightmares and traumatic memories from service had increased during the past year, right after his accident.  The diagnoses include PTSD with depression, and PTSD symptoms, and a GAF score of 55 due to PTSD.  

VA treatment records showed that in February 2010, the Veteran's GAF score was noted to be 66.  In May 2010, the Veteran was found to be well dressed and appearing neater than in the past.  He was in a bright and pleasant mood, and indicated he ceased thinking about going to school and would just work.  He believed he was capable of doing a very good job with his masters degree experience.  He denied any other problems.  In September 2010, he was seen for follow up and reported he was doing okay, was sleeping well, and his appetite was fine.  He denied suicidal and homicidal ideation and denied hallucinations.  He reported he stayed in the house mostly because he did not feel comfortable going out and meeting people because they "harm" him.  His mental status examination was unremarkable, and a GAF score of 60 was assigned.   

On a VA examination in June 2011, it was noted that the Veteran's present medical history included current treatment for a mental disorder, including an anti-depressant and anti-anxiety medication.  The answer was reported as "no" to the questions of whether symptoms were present during the past year, whether he had group therapy or individual therapy.  The effectiveness of therapy was noted to be "poor", and it was also noted that the Veteran was only occasionally seeing a psychiatric for care, and that he would like to get more treatment as he was aware that his PTSD was getting worse.  With regard to education, it was noted that he had stopped taking classes in person in 2010, because it was difficult for him to have to go out in public and have to interact with others, and now he only took online courses.  With regard to relationships, he reported that his family did not tell him when people died, and that being around people can result in fights and conflict, and that is what happened when he was around his relatives.  He indicated his family relationships were the worst, and if he had a problem with one, the other gets into it and they don't talk to him.  He reported he did not have friends, but that he may talk to someone when he goes out.  His activities and leisure pursuits involved doing things around his house.  He reported he watched too much television, and had a music library that he listened to when he was feeling better.  He reported he thought a lot about suicide, and always did, and claimed he had made several attempts in the past.  It was noted that the Veteran's perception of danger and increased isolation due to his fear of being harmed was evidence in his statements such as "people are evil" and that he did not like "to be around others".  He reported he kept to himself and tried to make his own life.  He reported he had problems even when he did not go out of his house, and indicating that he got stressed out over the horror coming out over the news.  He reported having significant anxiety when leaving the house.  It was noted that in contrast to his last evaluation, the Veteran was more isolated than in the past and was doing less with his time.  He also reported more stress and anxiety symptoms and having a harder time concentrating and keeping his attention focused on his tasks.  

Further, on the VA objective examination in June 2011, the Veteran was noted to be oriented, neatly groomed, cooperative, and suspicious, with an anxious mood, appropriate affect, and unremarkable psychomotor activity.  His thought process was unremarkable, but he had suicidal ideation and phobias.  He had attention disturbance in that he was easily distracted and had a short attention span.  He denied delusions and hallucinations.  His judgment and insight were intact.  He had sleep impairment because he could not sleep when he wanted to, and when he did sleep it was not that long.  He had some nightmares, and claimed his sleep had gotten worse in the past year.  It was noted that he had obsessive and ritualistic behaviors, described as safety-seeking behaviors indicative of hypervigilance.  He reported having panic attacks at home and out in public.  He had homicidal thoughts, and indicated he felt people were following him and out to do him harm. He was somewhat aware of being paranoid, but could not shake the feeling.  He had suicidal thoughts, describing them as persistent and prevalent, but denied current plan or intent.  His impulse control was described as fair.  With regard to having episodes of violence, the examiner noted "yes", and indicated that the Veteran's mood oscillated depending on his interactions with others and how much sleep he had, and the Veteran also indicated that he used to be really aggressive.  He was able to maintain minimal personal hygiene and had slight to severe problems with activities of daily living.  The examiner indicated that the Veteran's daily events were severely limited and that the Veteran would stay at home and did not get out unless he had to go to the store.  His memory was noted to be mildly impaired, and could be "jogged".  The examiner indicated that the Veteran had severe, chronic, and pervasive PTSD, and his PTSD appeared to have become more severe in the past year and a half.  The Veteran thought he was getting worse, and stated that he felt that his physical health and mental health had both declined in the past year.  He felt that his paranoia had gotten worse and things had gotten worse in the past year.  He reported that his family relationships had become more estranged, and that he only saw his sister two times a year, which was his most frequent contact.  He also reported not having friends and becoming more isolated in the past year and a half.  It was noted that he was unemployed, but not retired.  He had been unemployed for 20 years, reportedly due to stress, and indicated that both physical and mental health were barriers to completing tasks.  In that regard, it was noted that the Veteran could not be around others for a long period of time, and had problems with completing tasks and being able to remember and concentrate and get tasks done.  He had a history of aggressive behavior, and his current level of hypervigilance appeared to also impair his ability to interact with others in meaningful way.  He did not have interpersonal relationships and did not engage in meaningful tasks.  He took one course at a time, but was now doing those courses online so that he did not have to be around others or drive to the college location.  The examiner indicated that the Veteran's safety-seeking behaviors would impair his ability to engage in meaningful work, and that he literally taped up doors when he was home to keep others out.  The examiner opined that this kind of reaction to a perceived danger would be problematic in a workplace.  The examiner also noted that the Veteran had a difficult time staying on a train of thought when asked questions that were in relation to his stress or trauma.  The Veteran did not discuss his trauma in detail, but disclosed he was bullied, perceived a constant threat, and was also exposed to death and dismemberment.  

Finally, on the VA examination in June 2011, the diagnoses include PTSD, and a GAF score of 45, due to PTSD, was assigned, which was noted to represent an increase in his symptoms since his last evaluation.  The examiner noted that the Veteran's behaviors that indicated a GAF score of 45 included:  suicidal ideation, anxiety, paranoia, social isolation, strained family relationships, problems with concentration and memory, re-experiencing of trauma, hyperarousal, avoidance of trauma-related stimuli, change in mood related to stress when re-experiencing occurs, panic attacks, and lack of meaningful interactions or activities.  Additionally, his educational accomplishments had diminished since his last examination, and he had not been able to attend courses in person anymore.  The examiner reiterated that all areas of the Veteran's life appeared to have decreased since his last examination, and he did not appear to have much meaning in his tasks or his interactions with others.  With regard to his prognosis, the examiner noted that the Veteran had a positive experience living at the domiciliary in the early 1990s, but that his persistent and chronic PTSD most likely indicated that his likelihood of improvement was low overall and that his symptoms may be better managed through medication and learning more adaptive skills for addressing his re-experiencing symptoms.  The examiner opined that there was total occupational and social impairment due to PTSD signs and symptoms, noting that at this time, the Veteran's occupational and social functioning appeared to be severely adversely limited.  The examiner noted that the Veteran did not have any meaningful relationships and did not want to seek out relationships for fear that he would be harmed.  The examiner noted that the Veteran's occupational impairment was evident in his inability to hold a job for almost 20 years.  The examiner noted that the Veteran's history of suicidal ideation and multiple attempts were also indicative of the severity of his symptoms.  

VA treatment records showed that in June 2011, after the VA examination, the Veteran was seen for follow up.  It was noted that he was last seen in September 2010 and at that time his GAF score was 60.  He reported that all his "meds" had expired, and that his last refills for 60 days were in February 2011.  He had been spacing the meds as he was running out and had been more anxious lately.  His nightmares and flashbacks were sporadic and related to the military, and it was noted that he was a paramedic in Vietnam.  He avoided going out of the house in order to avoid triggers or getting anxious.  He denied hallucinations and suicidal and homicidal ideation.  His mental status examination was unremarkable, except for his mood being a little anxious and his affect restricted.  The assessment included history of PTSD, chronic, and rule out dementia.  A GAF score of 55 was assigned.  The examiner noted that the Veteran had thought-blocking for most of the interview and could not recollect his medication doses.  The Veteran attributed this to him being anxious to come to meeting today, but neuropsychiatric testing was to be done to rule out a secondary cause.  The examiner opined it could be related to PTSD, depression, and anxiety, noting that the Veteran lived alone and suggested that he follow up with therapy groups.  The Veteran denied any other concerns, and was aware to seek help if needed.  

A review of the Veteran's Virtual VA folder revealed that he was seen in August 2011 for a two month follow up appointment.  On interview, he was noted to be pleasant and polite, but very circumstantial.  He was unable to recall the specifics of the last appointment, and reported an episodes where he was cooking on the stove and burned his food and indicated this was a relatively common occurrence.  He denied any changes in mood, sleep, or appetitive, but endorsed difficulty sleeping due to living in a dangerous neighborhood  He denied any thoughts of self harm.  On mental status examination, he was found to be well-groomed and cooperative, with appropriate eye contact.  He mood and affect were okay and congruent, and his insight and judgment were limited.  The diagnoses included PTSD and rule out dementia.  A GAF score of 55 was assigned.

III. Analysis

1. Laws and Regulations

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.  38 U.S.C.A. § 1155; 38 C.F.R. § 4.1, Part 4.

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran.  38 C.F.R. § 4.3.

In general, when 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, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim.  Fenderson v. West, 12 Vet. App. 119 (1999).  Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified.  Hart v. Mansfield, 21 Vet. App. 505 (2007).

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission.  The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination.  When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment.  38 C.F.R. § 4.126.

The Veteran's psychiatric disability, to include, PTSD has essentially been evaluated as 30 percent disabling, effective from April 1, 1987.  Specifically, and for purposes of considering entitlement to a higher rating, it must be stated that in light of the temporary total ratings granted for periods of hospitalization, the Veteran's psychiatric disability, to include PTSD, has been rated as follows:  100 percent disabling, effective from December 3, 1986 (pursuant to 38 C.F.R. §4.29); 30 percent disabling, effective from April 1, 1987; 100 percent disabling, effective from February 1, 1990 (pursuant to 38 C.F.R. §4.29); and 30 percent disabling, effective from March 1, 1990.  

Complicating consideration of the Veteran's claim for a higher rating for PTSD, effective from December 3, 1986 to the present is the fact that the criteria for rating psychiatric disabilities were revised, effective November 7, 1996.  Thus, the Board will proceed with consideration of this appeal, applying the version of the criteria which is more favorable to the Veteran.  However, the revised version of the rating criteria will only be applied from the effective date of the regulatory change.  VAOPGCPREC 3-2000 (Apr. 10, 2000), 65 Fed. Reg. 33,421 (2000); Bernard v. Brown, 4 Vet. App. 384 (1993).  Thus, the new regulations may only be applied from the date they became effective forward.  For the period through November 6, 1996, the Veteran's psychiatric disability must be rated under the older criteria, regardless of whether the new criteria are more favorable to his claim; while, for the period from November 7, 1996, forward, the Veteran's claim should be rated pursuant to the set of criteria which is more favorable to his claim.  DeSousa v. Gober, 10 Vet. App. 461, 467 (1997); VAOPGCPREC 3-2000. 

Prior to November 7, 1996, Diagnostic Code (DC 9411) provided that a 30 percent rating was warranted when there was definite impairment in the ability to establish and maintain effective and wholesome relationships with people, and the psychoneurotic symptoms resulted in such reductions in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment.  38 C.F.R. § 4.130, DC 9411 (1996).  

In a precedent opinion, VA's General Counsel concluded that "definite" is to be construed as "distinct, unambiguous, and moderately large in degree."  It represents a degree of social and industrial inadaptability that is "more than moderate but less than rather large."  VAOPGCPREC 9-93; 59 Fed. Reg. 4752 (1994).  The Board is bound by this interpretation of the term "definite."  38 U.S.C.A. § 7104 (c). 

Further, prior to November 7, 1996, DC 9411 provided that a 50 percent rating required that the ability to establish or maintain effective or favorable relationships with people be considerably impaired, and that, by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels be so reduced as to result in considerable industrial impairment.  A 70 percent rating required that the ability to establish and maintain effective or favorable relationships with people be severely impaired, and that the psychoneurotic symptoms be of such severity and persistence that there was severe impairment in the ability to obtain or retain employment.  38 C.F.R. § 4.130, DC 9411 (1996).  A 100 percent rating required that the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community; psychoneurotic symptomatology bordering on gross repudiation of reality; or demonstrable inability to obtain or retain employment.  Id; see also Johnson  v. Brown, 7 Vet. App. 95 (1994) (holding that the criteria in 38 C.F.R. § 4.132  for a 100 percent rating are each independent bases for granting a 100 percent rating). 

Under the revised rating criteria, effective November 7, 1996, there is a general rating formula for mental disorders, under which a 30 percent rating is warranted when there is 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).  38 C.F.R. § 4.130.  A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as:  flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (for example, 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.

A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships.  Id.  A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.  Id.

The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations.  Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment.  Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). 

In addition to the applicable rating criteria, in evaluating the Veteran's major depressive disorder, the Board has also considered the Global Assessment of Functioning (GAF) scores assigned, and the definition of those scores.  According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness."  There is no question that the GAF score and the interpretations of the score are important considerations in rating a psychiatric disability.  See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995).  However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, they must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned).  See 38 C.F.R. § 4.126(a). 

2. Discussion

The Veteran contends that his PTSD has been more disabling than currently evaluated.  As noted above, the Veteran's psychiatric disability, to include PTSD, has been rated as follows:  100 percent disabling, effective from December 3, 1986; 30 percent disabling, effective from April 1, 1987; 100 percent disabling, effective from February 1, 1990; and 30 percent disabling, effective from March 1, 1990.  

As the amended version of the rating criteria, effective November 7, 1996, are only applicable from the effective date of the change, the Board will first consider entitlement to an initial rating in excess of 30 percent for a psychiatric disorder, to include PTSD, for the period prior to November 7, 1996, based on the rating criteria in effect prior to November 7, 1996.  Then, the Board will consider entitlement to a rating in excess of 30 percent for a psychiatric disorder, to include PTSD, for the period effective from November 7, 1996, to February 20, 2007, based on both the old and revised rating criteria, and apply the version most favorable to the Veteran.

a. Higher Rating prior to November 7, 1996

In order for a rating in excess of 30 percent to be granted under the old rating criteria for psychiatric disorders, the competent evidence of record would need to show that the ability to establish or maintain effective or favorable relationships with people be considerably impaired, and that, by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels be so reduced as to result in considerable industrial impairment.  38 C.F.R. § 4.132, DC 9411 (1996).  

On review of the competent evidence of record, which primarily includes VA treatment records showing group and individual therapy, medication management, and a period of residence at a VA domiciliary in the early 1990s; several VA examination reports; and VA hospitalization reports, the Board notes that the Veteran's psychiatric symptoms have primarily manifested as nightmares, flashbacks, depression, flattened affect, paranoia, anxiety, anger, and problems with sleep, and that his mental status examinations were for the most part unremarkable, but did include notations at various times of a depressed mood, flat affect, problems with memory, concentration, judgment, and insight.  In addition, at times he had complaints of suicidal thoughts - however, these occurred mostly during periods of hospitalization (for which has already been assigned temporary total ratings), or were characterized as suicidal thoughts, with no plan or intent, and the Veteran had safety plans.  For the most part the Veteran denied suicidal and homicidal ideation, as well as denied hallucinations.  He had reports of hallucinations on only a few occasions, but the medical provider questioned whether these were true hallucinations.  Also the record reflects that during this time period, the Veteran was actively seeking a job, and did hold several, albeit temporary jobs, up until the early 1990s, when he apparently stopped working due to his various disabilities.  The evidence of record dated prior to November 7, 1996, basically showed that the Veteran clearly had problems with employment due to both his physical and mental disabilities, however, he was able to work, received vocational rehabilitation and training, and continued to look for work until the early 1990s.  Additionally, he underwent a VA examination in April 1996, during which his incapacity was assessed as mild, and a GAF score of 60 was assigned.  Although GAF scores are only one aspect of rating a psychiatric disability, and a GAF score of 60 is consistent with the mild to moderate symptomatology and does not support the assignment of a rating in excess of 30 percent, for the Veteran's psychiatric disorder, prior to November 7, 1996.

Thus, the Board concludes that the objective evidence as a whole, dated prior to November 7, 1996, shows that under the old schedular criteria for a psychiatric disorder, the Veteran's symptoms attributable to his psychiatric disorder were not productive of considerable impairment in the ability to establish or maintain effective or favorable relationships or productive of considerable industrial impairment.  Specifically, the Veteran received ongoing therapy - both group and individual, was hospitalized several times, and lived in a VA domiciliary for an extended period of time.  He reported he isolated himself, and had trouble with family relationships, but he did have some friends and had some socialization through work and the domiciliary.  With regard to employment, the Veteran attributed his problems to his mental and physical disabilities, and it was noted that he was able to work up until the early 1990s, and that he had stopped working in part due to physical disabilities.  Thus, based on foregoing and the fact that the Veteran continued to work, and then seek employment and training during the time period in question, the Board finds that the evidence does not show that the Veteran experienced considerable industrial impairment due to psychiatric symptoms.  

Considering the aforementioned lay and clinical findings in the record on appeal, the Board finds that although the Veteran's symptoms and complaints and situation fluctuated somewhat throughout the period in question, the evidence of record collectively indicates that, prior to November 7, 1996, the Veteran's occupational and social impairment was no more than mild to moderate, and that he was not considerably occupationally and socially impaired to the extent that a rating in excess of 30 percent was warranted under the old criteria.  38 C.F.R. § 4.132, DC 9411 (1996).  


b. Higher Rating from November 7, 1996

In order for a rating in excess of 30 percent to be granted from November 7, 1996, the competent evidence of record would basically need to show either (pursuant to the old regulation) considerable impairment in the ability to establish or maintain relationships with people and considerable industrial impairment.  38 C.F.R. § 4.132, DC 9411 (1996).  Or, pursuant to the revised regulation, in order for a rating in excess of 30 percent to be granted, the competent evidence of record would need to show occupational and social impairment with reduced reliability and productivity due to symptoms such as those listed in the criteria for a 50 percent rating under DC 9411, and/or as other symptoms attributed to his service-connected psychiatric disability, to include PTSD.  38 C.F.R. § 4.130, DC 9411; Mauerhan v. Principi, supra

The evidence of record dated subsequent to November 7, 1996 consists of several VA examination reports, reports of VA hospitalizations, private records, and records from the SSA.  After reviewing the pertinent medical evidence of record, the Board finds that the veteran's PTSD manifestations do not meet the criteria for a rating in excess of 30% under either the old or the revised rating criteria, effective from November 7, 1996.  In that regard, the Board notes that the Veteran clearly has some industrial and social impairment.  The record reflects that the Veteran lives alone, tends to isolate himself, and was estranged from most of his family members.  He had, however, indicated he has some friends.  Moreover, in consideration of the Veteran's occupational impairment, while it is clear he has not worked since the early 1990s, his employment problems have been attributed to his physical disabilities, as well as mental disabilities.  Significantly, the Board notes that the evidence of record showed that the Veteran completed a computer training program in school and was actively pursuing job opportunities.  Moreover, the competent medical evidence showed that the Veteran continued to exhibit nightmares, flashbacks, depression, flattened affect, paranoia, anxiety, anger, and problems with sleep, and that his mental status examinations were for the most part unremarkable, but did include notations at various times of a depressed mood, flat affect, problems with memory, concentration, judgment, and insight.  In addition, at times he had complaints of suicidal thoughts - however, he reported having no plan or intent, and that he had safety plans.  For the most part the Veteran denied suicidal and homicidal ideation, as well as denied hallucinations.  

In sum, the objective evidence of record does not establish that manifestations of PTSD resulted in considerable social and industrial impairment, the criteria required for a 50 percent rating under the regulations in effect prior to November 7, 1996.  In this regard, the Board notes that during this period, the Veteran was assigned GAF scores ranging from 45 (in June 2011) to 50 to 65 (in January 2008).  While the GAF score of 45 will be separately discussed below, the Board notes that the GAF scores ranging from 50 to 65 show mild to moderate impairment only, and, therefore such scores do not reflect industrial impairment that is more than definite, or suggest disability in excess of that contemplated by the 30 percent rating which is currently assigned.  

With respect to the revised rating criteria effective on and after November 7, 1996, the Board also finds that a 50 percent rating is not warranted.  Although there has been evidence showing that the Veteran has had social impairment as a result of his PTSD, including isolating himself and not getting along with people, he also attended school and actively was seeking out job opportunities.  Moreover, while the Veteran did have at least some occupational impairment due to his PTSD, and even received SSDI payments in part based on his psychiatric disorder, the record also reflects he continued to seek vocational training and employment.  In addition, while he had some instances of flattened affect, for the most part his speech and memory were intact, there was no difficulty in understanding complex commands; and his thinking and thought processes were not impaired.  Accordingly, the Board finds that the manifestations of the veteran's PTSD do not warrant a 50 percent rating under either the old or the revised rating criteria; rather, they more nearly approximate the criteria for the currently-assigned 30 percent rating. 


c. Evaluation from June 11, 2011

The Board is able to find support for a grant of a 70 percent rating for the Veteran's psychiatric disorder, to include PTSD, effective from June 11, 2011, the date of the most recent VA psychiatric examination.  This latter VA examination clearly showed that the Veteran's psychiatric symptoms had worsened, and that a GAF score of 45 was assigned based on the following behaviors exhibited by the Veteran, some of which he had through the appeal period, and others which were somewhat new including suicidal ideation, anxiety, paranoia, social isolation, strained family relationships, problems with concentration and memory, re-experiencing of trauma, hyperarousal, avoidance of trauma-related stimuli, change in mood related to stress when re-experiencing occurs, panic attacks, and lack of meaningful interactions or activities.  Additionally, his educational accomplishments had diminished since his last examination, and he had not been able to attend courses in person anymore.  The examiner reiterated that all areas of the Veteran's life appeared to have decreased since his last examination, and he did not appear to have much meaning in his tasks or his interactions with others.  Moreover, the examiner opined that there was total occupational and social impairment due to PTSD signs and symptoms, noting that at that time, the Veteran's occupational and social functioning appeared to be severely adversely limited.  Thus, it appears that as of June 11, 2011, after resolving any doubt in the Veteran's favor, that his service-connected psychiatric disorder met the criteria for the assignment of a 70 percent rating, pursuant to both the old and the revised rating criteria.  38 C.F.R. § 4.130, DC 9411.  

In order for an even higher rating of 100 percent to be assigned, however, the evidence of record would have to basically need to show total industrial/occupational and social impairment.  In that regard, the Board notes that the evidence of record, which includes the VA examination report dated in June 2011 and subsequent VA treatment records, which includes an opinion from the VA examiner that the Veteran had total occupational and social impairment, but also a statement to the affect that his occupational and social functioning were severely adversely limited, does not show that his psychiatric disorder is of such magnitude as to support the assignment of a 100 percent schedular rating.  In reaching these determinations, the Board has been mindful of the of the benefit-of-the-doubt doctrine.  In that regard, the Board acknowledges that a GAF score of 45 was assigned at the time of the VA examination in June 2011, which reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job).  See DSM-IV.  However, as noted above, the GAF score is only one factor to be considered in ascertaining the degree of impairment caused by the veteran's psychiatric illness.  Moreover, subsequent to the VA examination, the Veteran was seen for two follow up VA appointments, at which time a GAF score of 55 was assigned.  Thus, the GAF scores ranged from 45 to 55 in the period of two months, which mirrors the Veteran's psychiatric symptoms during that same time period, which appeared to fluctuate from the VA examination to the subsequent VA appointments.

With regard to whether a higher rating of 100 percent is warranted for the Veteran's psychiatric disorder during the time period in question, the Board notes that the Veteran's disability picture due to his service-connected depression more nearly approximates the criteria for a 70 percent rating than for a 100 percent rating. 38 C.F.R. § 4.7 . With regard to the specific criteria for a 100 percent rating, the Board notes that the competent evidence of record does not show that his psychiatric disorder, to include PTSD, is productive of total occupational and social impairment.  With regard to work, although it appears that his employment has been severely affected, the fact remains that in the past his employment problems, and his SSDI, stem from physical as well as mental disabilities.  Moreover, with regard to social impairment, the Board notes that, while the Veteran's isolation appeared to have worsened as of the June 2011 VA examination, he still maintained some contact with a sister and was willing to consider group therapy.  Also, the Board notes that the Veteran was not found to have a formal thought disorder, and had no report of delusions or hallucinations, and no inappropriate behavior was noted.  Although it was noted that he had suicidal thoughts and attempts in the past, he was aware to seek help if needed.  It was also noted that he denied suicidal ideation.  Complicating the Veteran's situation and most likely his examination findings is the proposition that he might have some sort of dementia, which was noted on the VA examination in June 2011 and the subsequent VA treatment records.  However, the Board notes that herein all of the symptoms and manifestations listed on the June 2011 VA examination and treatment records have been considered here in the assignment of a 70 percent rating, effective from June 11, 2011. 

Thus, for reasons set forth above, the Board concludes that the evidence of record does not show that the Veteran's disability picture due to his service-connected depression approximates the criteria for a 100 percent rating under either the old or the revised rating criteria for psychiatric disabilities.  Rather, giving the Veteran the benefit of any reasonable doubt, the criteria for a 70 percent rating for his psychiatric disorder, but no more, have been met, effective from June 11, 2011.  38 C.F.R. § 4.130, DC 9411.  The evidence as a whole demonstrates that the Veteran's psychiatric/PTSD symptoms do not approximate the criteria for a 100 percent rating at any time during the period in question.  38 C.F.R. § 4.7.  While the evidence of record shows that the Veteran has severe occupational and social impairment, and has deficiencies in work, family relations, mood, and at times in his judgment and thinking, the Veteran's symptoms due to his psychiatric disorder and PTSD do not approach or approximate the magnitude of the symptoms listed in the criteria for a 100 percent rating under DC 9411.  

The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his psychiatric condition.  The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects.  Medical evidence is generally required to address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes.  Espiritu v. Derwinski, 2 Vet. App. 492, 494   (1992).  However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation.  38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence).  In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms.  The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

In conclusion, the Board finds that the preponderance of the evidence is against the claim for an evaluation in excess of a 30 percent for the service-connected PTSD effective prior to June 11, 2011, but, after the resolution of any doubt in the Veteran's favor, supports the grant of a 70 percent evaluation for the service-connected psychiatric disorder, to include PTSD, effective from June 11, 2011. 

3. Extraschedular Consideration

The Board also finds that the Veteran's psychiatric disability, to include PTSD, does not warrant referral for extra-schedular consideration at any point during the appeal period.  In exceptional cases where schedular disability ratings are found to be inadequate, consideration of an extra-schedular disability rating is made.  38 C.F.R. § 3.321(b)(1).  There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate.  Thun v. Peake, 22 Vet. App. 111 (2008).  First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule.  Id.   If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms."  Id.; see also 38 C.F.R. § 3.321(b)(1).  If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating.  Id.  

In the present case, the Board finds that the Veteran's disability picture due to his service-connected psychiatric disability, to include PTSD, is adequately contemplated by the rating schedule, especially since the rating criteria (DC 9411) specifically take into account social and occupational functioning in assessing the severity of the psychiatric disorder and PTSD, and provides for a greater evaluation for more severe impairment.  The record reflects that the Veteran previously worked as full time, and then started to receive SSDI payments due in part to other disabilities and in part to his service-connected psychiatric disorder .  While he has claimed that his service-connected psychiatric disorder, to include PTSD, affects his ability to work, herein, as explained above, the rating criteria for his service-connected psychiatric disability reasonably describes his disability level and symptomatology.  Thus, the Board concludes that the first prong of the Thun analysis has not been satisfied in this case, the criteria for referral for the assignment of an extraschedular disability rating are not met, and the Board declines to remand this matter for referral for extraschedular consideration.  38 C.F.R. § 3.321(b)(1); Thun v. Peake, supra. 

ORDER

Prior to June 11, 2011, the claim for a rating in excess of 30% for a psychiatric disability, to include PTSD, is denied. 

Effective from June 11, 2011, the claim for a higher 70 percent rating for a psychiatric disability, to include PTSD, is granted, subject to the laws and regulations governing the payment of monetary benefits.   


REMAND

1. Compensable Rating for Scars of the Head, Face, or Neck

The record reflects that the Veteran has expressed disagreement with the June 2009 RO rating decision, which denied a compensable rating for scars of the head, face, or neck.  Pursuant to Manlincon v. West, supra, he must therefore be provided with an SOC regarding whether the claim for a compensable rating for scars of the head, face, or neck, so that he has the opportunity to perfect this appeal.  Only if the appeal is perfected should the issue be returned to the Board for appellate review. 

2. TDIU rating

As noted above, the Board finds that the record has raised an inferred claim for a TDIU rating.  Rice v. Shinseki, supra.  The Veteran has essentially contended that due to his combined disabilities, he has been unable to obtain or maintain employment.  Therefore, and in light of Rice v. Shinseki, supra, the fact that the Veteran has not received appropriate notice regarding this issue,  and that this issue is inextricably intertwined with other issues on appeal, the Board finds that the claim for a TDIU rating must be remanded to the RO for further development.

Accordingly, the case is REMANDED for the following action:

1. The Veteran and his representative should be provided an SOC on the issue of entitlement to a compensable rating for scars of the head, face, or neck.  If, and only if, a substantive appeal is filed, this issue should be returned to the Board for appellate review. 

2. With regard to the claim for a TDIU rating, ensure VCAA compliance and afford the Veteran the opportunity to submit additional argument and evidence on the claim.

3. Schedule the Veteran for a VA examination to determine whether his service-connected disabilities, either alone or in combination prevent him from securing or following employment for which his education and occupational experience would otherwise qualify him.

The claims file, including this remand, must be sent to the examiner for review; consideration of such should be reflected in the completed examination report.  The examiner is requested to opine as to whether it is at least as likely as not that the Veteran's service-connected disabilities, either alone or in combination (and without regard to age or non-service-connected disabilities), preclude him from securing or following substantially gainful employment for which his education and occupational experience would otherwise qualify him. 

The examiner must provide reasons for the opinion.  If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered.

The examiner is advised that the Veteran is competent to report his symptoms and history and such reports must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so.

4. After the above is completed, as well as any other development deemed necessary, adjudicate the claims.  If any determination is adverse to the Veteran, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and return the case to the Board.

The appellant has the right to submit additional evidence and argument on the matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).  This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011).



______________________________________________
S. L. Kennedy
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs