Citation Nr: 1318140 Decision Date: 06/04/13 Archive Date: 06/11/13 DOCKET NO. 03-16 239 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder, initially evaluated as 50 percent disabling prior to May 1, 2005, noncompensably disabling from May 1, 2005 to May 2, 2012, and 30 percent disabling thereafter. REPRESENTATION Appellant represented by: Roger W. Rutherford, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran had active duty for training from June 16 to October 22, 1988, and additional active service from September 12 1990, to June 10, 1991, with service in support of Operation Desert Shield\Desert Storm from October 25, 1990 to May 9, 1991. This case originally came before the Board of Veterans' Appeals (Board) on appeal of a December 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which decision granted service connection (and a 50 percent evaluation) for posttraumatic stress disorder effective from June 12, 1998, the date of receipt of the Veteran's original claim. In an October 2004 rating decision, the RO proposed to reduce the evaluation assigned for the Veteran's service-connected posttraumatic stress disorder from 50 percent to noncompensably disabling. The Veteran was notified of that proposal by official letter dated October 27, 2004. In a decision of February 2005, the RO effectuated the aforementioned reduction for the Veteran's service-connected posttraumatic stress disorder from 50 percent to noncompensable, effective from May 1, 2005. In a subsequent decision of November 2005, the Board denied entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder for the period prior to May 1, 2005, as well as entitlement to a compensable rating for the period from May 1, 2005. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which, in a November 2007 Memorandum Decision, vacated the Board's November 2005 decision and remanded the case to the Board for action consistent with that Memorandum Decision. In March 2009, the Veteran's case was remanded to the RO via the Appeals Management Center (AMC) in Washington, D.C. for additional development. The case is now, once more, before the Board for appellate review. In association with the prior decision, appellant appeared at a Travel Board hearing in August 2005. The Veterans Law Judge who conducted that hearing is no longer at the Board. Appellant was offered the opportunity for an additional hearing, but did not respond to the letter of March 2013. As indicated in that letter, the Board with proceed with a decision as further hearing was not requested. For reasons which will become apparent, the appeal as to the issue of entitlement to a compensable rating for service-connected posttraumatic stress disorder for the period from May 1, 2005 to May 2, 2012 is once again being REMANDED to the RO. VA will notify you if further action is required on your part. The Veteran has variously claimed that he is not employed secondary to his PTSD and due to diabetes and other problems. If he desires to file a claim based on his service connected disorder, he should do so with specificity at the RO. FINDINGS OF FACT 1. Prior to May 1, 2005, the Veteran's service-connected posttraumatic stress disorder was productive of no more than occupational and social impairment, with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 2. From May 2, 2012, the Veteran's service-connected posttraumatic stress disorder has been productive of no more than 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, and/or mild memory loss (such as forgetting names, directions, or recent events). CONCLUSIONS OF LAW 1. Prior to May 1, 2005, the criteria for an initial evaluation in excess of 50 percent for posttraumatic stress disorder were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130 and Part 4, Diagnostic Code 9411 (2012). 2. From May 2, 2012, the criteria for an evaluation in excess of 30 percent for posttraumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130 and Part 4, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, the requirements of the Veterans Claims Assistance Act of 2000 (VCAA) have been met. Moreover, as service connection, an initial rating, and an effective date have been assigned for the Veteran's service-connected posttraumatic stress disorder, the notice requirements of 38 U.S.C.A. § 5103(a) (West 2002) have also been met. Currently, there is no issue as to whether the Veteran was provided an appropriate application form, or the completeness of his application. VA notified the Veteran in August 2001, June 2002, and September 2003, as well as in July 2005 and May 2009, of the information and evidence needed to substantiate and complete his claim, to include notice of what part of that evidence was to be provided by him, and what part VA would attempt to obtain. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Increased Rating In reaching this determination, the Board has reviewed all the evidence of the Veteran's claims file, which includes his multiple contentions, including those offered during the course of a Travel Board hearing in August 2005, as well as service treatment records, and both VA (including Virtual VA) and private treatment records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to that claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran in this case seeks an increased evaluation for service-connected posttraumatic stress disorder. In pertinent part, it is contended that manifestations of that disability are more severe than currently evaluated, and productive of a greater degree of impairment than is reflected by the respective 50 percent and 30 percent schedular evaluations now assigned. In that regard, disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two evaluations apply, the higher evaluation will be assigned where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). While the Board must consider the Veteran's medical history as required by various provisions under 38 C.F.R. Part 4, including 38 C.F.R. § 4.2 [see Schafrath v. Derwinski, 1 Vet. App. 589 (1991)], the degree of impairment resulting from a service-connected disability is a factual determination, with the Board's primary focus on such cases being upon the current severity of the service-connected disability. See Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the Francisco rule does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an award of service connection for the disability in question. Rather, at the time of the initial rating, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id., at 126. Accordingly, the analysis in this decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings are to be based as far as practicable upon the average impairment of earning capacity, with the additional proviso that the Secretary shall, from time to time, readjust the schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits, or the Director, Compensation & Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in 38 C.F.R. § 3.321 an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases if a finding that the case presents such an exceptional or unusual disability picture, with such related factors as a marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). In that regard, in a rating decision of December 2002, the RO granted service connection and a 50 percent evaluation for posttraumatic stress disorder, effective from June 12, 1998, the date of receipt of the Veteran's original claim for service connection. The Veteran voiced his disagreement with the assignment of that 50 percent evaluation, and the current appeal ensued. In that regard, at the time of a period of VA hospitalization in May 1998, the Veteran indicated that he felt as if he were "losing control." According to the Veteran, he had experienced problems with a depressed mood and rage since his service in the Persian Gulf. Further noted was a loss of appetite, as well as reported insomnia and nightmares, although, by the Veteran's own admission, he was unable to remember most of his nightmares. When questioned, the Veteran denied any visual hallucinations. While according to the Veteran, he had heard voices in the past, he currently was experiencing no such problem. The Veteran denied thought insertion, thought broadcasting, and ideas of reference, and similarly denied any problems with paranoia. While admitting to passive suicidal thoughts, the Veteran denied any suicidal plan and similarly denied problems with homicidal thoughts. When further questioned, the Veteran reported flashbacks of "charred bodies and odors," as well as the "smell of burning bodies." While according to the Veteran, while in service, he functioned as a cook, he reportedly saw the aforementioned bodies "when going from one station to another station." On mental status examination, the Veteran appeared angry, with a congruent mood. However, he was both alert and well-oriented. The Veteran's speech was normal in rate and volume, and there was no evidence of any looseness of association. While during his hospital stay, the Veteran continued to be somewhat irritable and judgmental of others, he did report that his insomnia improved, and that his nightmares had decreased in frequency. The Veteran was subsequently referred to Alcoholics Anonymous, with a suggestion that he continue such treatment as an outpatient. While hospitalized, the Veteran underwent psychological testing, which yielded a clinical impression of an attitude problem characterized by belligerence, as well as demanding and negative expectations of those around him, with a very low frustration tolerance and very poor impulse control. Psychometric testing was mixed, characterized by an invalid MMPI-II due to "over reporting of symptoms," felt to be typical for Veterans who attribute disabling consequences to their time in service. Significantly, the psychometric instrument used for assessing character pathology was significant for a marked elevation of antisocial, aggressive, and sadistic skills. Such findings were felt to be valid, as verified by the Veteran's clinic presentations. At the time of discharge, the Veteran reported that his mood was improved and that his insomnia was "much better." Moreover, he denied both suicidal and homicidal thoughts. The pertinent diagnoses noted were adjustment disorder with depressed mood; history of alcohol dependence, in remission; and antisocial personality traits. At the time of discharge, the Global Assessment of Functioning Score was 50. At the time of a subsequent period of VA hospitalization in September and October 1998, the Veteran gave a history of a depressive disorder (not otherwise specified), as well as "rule out" posttraumatic stress disorder. At the time of the admission, the Veteran endorsed suicidal ideation, but denied any homicidal ideation. Additionally noted were auditory/visual hallucinations with regard to Desert Storm, as well as hypervigilance with "positive flashbacks." According to the Veteran, while he had been a cook during Desert Storm, he had witnessed "shooting and dead bodies." Additionally noted was a depressed mood secondary to the Veteran's girlfriend's diagnosis of lung cancer. According to the Veteran, for the past couple of months, he had endorsed decreased energy, decreased concentration, hopelessness, and helplessness. However, there were no psychotic features with the exception of some auditory/visual hallucinations related to claimed combat exposure, which, in the opinion of the evaluating team, needed verification prior to a diagnosis of posttraumatic stress disorder. On mental status examination at the time of admission, the Veteran was cooperative, and both alert and well-oriented. Eye contact was described as fair, and while the Veteran's mood was upset and worried, his affect was congruent. Thought processes were circumstantial, with thought content consistent with suicidal ideation, as well as perceptual changes. At the time of admission, both insight and judgment were described as somewhat impaired. During hospitalization, it was noted that the Veteran had been admitted due to suicidal ideation and depressive symptoms secondary to his problems in life, to include his girlfriend having been diagnosed with cancer and receiving both chemotherapy and radiation therapy. According to the Veteran, this had been extremely stressful for him. During his hospital stay, the Veteran's mood improved, and he responded well to medications. The Veteran went on a five-hour pass with his girlfriend, and, following his return, indicated that he had married her, and that she was now his wife. Over the course of the next couple of days, the Veteran began enjoying the various groups in which he was participating, with the result that his mood and sleep appeared to be getting better. The Veteran additionally reported a reduction in the intensity of the auditory/visual hallucinations related to his posttraumatic stress disorder symptoms, as well as a reduction in nightmares and flashbacks. At the time of discharge, the Veteran had ceased voicing any suicidal ideation. Mental status examination at the time of discharge showed the Veteran to be alert and well-oriented, with a good mood and congruent affect. The Veteran's speech was of normal rate and volume, and his thought processes were goal-directed. Thought content was free of homicidal or suicidal ideation, and both insight and judgment were described as average. The pertinent diagnoses noted were depressive disorder, not otherwise specified; simple phobia; anxiety disorder, not otherwise specified; and antisocial personality traits (according to the Veteran's chart). The Global Assessment of Functioning Score, apparently, at the time of admission, was 20. At the time of a VA psychiatric examination in early January 1999, it was noted that the Veteran's claims folder was available, and had been reviewed. According to the Veteran, while in the Persian Gulf, he had spent most of his time as a cook, and some time as a mechanic. When questioned, the Veteran described incidents in which, while cooking for the troops, he could see "piles of dead Iraqi bodies" accompanied by a "bad smell." According to the Veteran, the aforementioned smell disturbed him, and continued to disturb him even today. When questioned regarding his complaints, the Veteran indicated that he often became depressed and "very nervous." Also noted were problems with crying spells, though with "good energy and appetite." According to the Veteran, he experienced problems with insomnia, as well as occasional nightmares, though, by his own admission, he was unable to remember or describe those nightmares. The Veteran indicated that he missed his wife daily, given that she had died from breast cancer the previous November. The Veteran further indicated that he had no problem trusting people if those people had no intention of harming him. Moreover, he did not experience any physiological reaction with exposure to events or aspects which resembled his inservice traumatic event. The Veteran stated that he enjoyed pleasurable activities, and was not detached from others. Moreover, both his affect and feelings were "broad-ranged." While the Veteran indicated that he at times experienced difficulty staying asleep, he was not hypervigilant, nor did he experience an exaggerated startle response to sound. On mental status examination, the Veteran displayed good hygiene and eye contact. He was both cooperative and pleasant, though at times, he appeared anxious. The Veteran was alert and oriented in all spheres. While his mood was anxious, his affect was mood congruent. Thoughts were described as goal-oriented, and there was no evidence of either visual or auditory hallucinations. Nor was there evidence of delusions, or either suicidal or homicidal ideation. Immediate, recent, and remote memory were described as intact, as was the Veteran's judgment. According to the examiner, the Veteran displayed "few posttraumatic stress disorder symptoms," though he did indicate that he had read a book about posttraumatic stress disorder. Significantly, in the opinion of the examiner, the Veteran did not meet the full criteria for a diagnosis of posttraumatic stress disorder. The pertinent diagnoses noted were anxiety not otherwise specified; depression, not otherwise specified; and ethanol dependence, in full remission. At the time of examination, the Veteran's Global Assessment of Functioning Score was 65. At the time of a subsequent period of VA hospitalization in early January 1999, it was noted that the Veteran carried a diagnosis of depression, as well as a past history of substance abuse, currently in remission. Reportedly, following a previous discharge, the Veteran had become more upset and depressed due to his social stressors. Apparently, the Veteran had gone to stay with and take care of his niece, who was paraplegic, but then left her and returned to Virginia. At that time, the Veteran reportedly began feeling depressed, with poor concentration and energy, as well as feelings of hopelessness and helplessness. Noted at the time of admission was that the Veteran was a Persian Gulf War Veteran who had worked as a cook. While according to the Veteran, he had seen combat, there were contradictory reports from the staff compared to what the Veteran had been reporting. Significantly, at the time of admission, the Veteran denied any manic or psychotic symptoms. During his hospital stay, it was noted that the Veteran had been admitted with a diagnosis of recurrent major depressive disorder. Further noted was that the Veteran's case had been formally presented, his chart reviewed, and his stressors explored. Significantly, the Veteran appeared to have dependent and borderline personality traits, and was very vague in his symptomatology, indicating that he had been having difficulty finding and maintaining a job. During hospitalization, a second opinion was obtained from a VA physician who had seen the Veteran on four previous occasions. That physician thought that the Veteran had been "somatizing and malingering" some of his symptoms for secondary gain. Significantly, other hospital staff came to a similar conclusion that the Veteran had been somatizing a lot of his symptoms, and that he appeared to contradict his reports of symptomatology. On mental status examination at the time of discharge, the Veteran was dressed and groomed rather poorly, with somewhat poor hygiene. However, there was no evidence of any abnormal movements. While the Veteran was pleasant, he was very passive aggressive at times. The Veteran's mood was described as dysphoric, with an irritable affect. However, his thought processes were clear, logical, and goal-directed, and there was no evidence of either suicidal or homicidal ideation. Nor did the Veteran exhibit any thought insertion or thought broadcasting. At the time of discharge, there was no evidence of either hallucinations or delusions. However, judgment was fair to poor, and insight poor. The diagnoses noted were depressive disorder, not otherwise specified; "rule out" posttraumatic stress disorder; and personality disorder, not otherwise specified, with the Veteran exhibiting poor impulse control, passive aggressive behavior, and very little concern for other's feelings or social appropriateness. Significantly, previous records indicated the presence of anti-social personality traits. The Global Assessment of Functioning Score at the time of discharge was 55. On subsequent VA hospitalization in late September 1999, there was noted a history of severe recurrent major depressive disorder, as well as a "possible history" of posttraumatic stress disorder. Further noted was that the Veteran was a Persian Gulf War Veteran, though he had not received a diagnosis of posttraumatic stress disorder due to the fact that he did not "meet enough symptoms for the diagnosis." At the time of admission, the Veteran complained of depression, with poor concentration and energy, and accompanying feelings of hopelessness and worthlessness, primarily due to the fact that he was confronting the first anniversary of the death of his wife, who had died the previous year. According to the Veteran, he was currently living with a friend and her children, and was interested in moving into town. During hospitalization, the Veteran was involved in individual and group counseling. Significantly, during that counseling, the Veteran appeared to have an affect which was not congruent with his mood, given that, while he was reportedly grieving over his ex-wife's death, he was quite interactive with hospital staff. In that regard, when seen on an individual basis by the resident physician, nursing staff, and attending physician, the Veteran was "very open" and denied any history of depression. Moreover, while on one hand, the Veteran was describing his grief over his ex-wife's death, at the same time, he appeared to be interacting happily with his girlfriend. On mental status examination, the Veteran was well-oriented. His mood was described as better, and his affect not anxious. When questioned, the Veteran denied both suicidal and homicidal ideation. Moreover, his thoughts were logical, coherent, and goal-directed. At the time of evaluation, both judgment and insight were described as fair. The pertinent diagnoses noted were severe recurrent major depressive disorder, rule out dysthymia; and dependent and borderline personality traits, with a Global Assessment of Functioning Score at discharge of 60. On subsequent VA hospitalization in June 2001, the Veteran was described as well-groomed, clean, and appropriately dressed. The Veteran was alert and well-oriented, though his speech was a bit pressured. Otherwise, the Veteran appeared to be somewhat anxious and irritable. Long-term memory was described as good, while recent and immediate functions were "poor." Thought processes were logical and goal-directed, and the Veteran denied both auditory and visual hallucinations. Ideas of reference and paranoia were similarly denied, and both insight and judgment were described as fair. At the time of a subsequent VA psychiatric examination in April 2002, it was noted that the Veteran's claims folder, as well as electronic and paper medical records were available, and had been reviewed. On mental status examination, the Veteran was dressed informally, with reasonably good grooming. There was no evidence of any unusual tics or mannerisms, and the Veteran's speech fluency and articulation were unremarkable, as were his speech, tone and rate. The Veteran was generally socially appropriate throughout the interview, and appeared to attempt to cooperate. Significantly, over the course of the interview, the Veteran appeared to develop a fairly good rapport with the interviewer. Nonetheless, the Veteran described his mood as "upset," and indicated that he was "feeling groggy and sluggish" from lack of sleep. According to the examiner, this was generally consistent with the Veteran's overall affect. In general, the Veteran's affect was described as somewhat constricted, and at times anxious. Nonetheless, the Veteran was oriented in all four spheres. The Veteran showed no evidence of suicidality or homicidality, and denied that he had been thinking about suicide. Moreover, the Veteran denied having homicidal thoughts regarding any particular people. While according to the Veteran, he was subject to "feelings of rage," this was not directed at any particular person. The Veteran described his mood as upset and aggravated, and perhaps "a little despondent." Significantly, when confronted by how he must be feeling, the Veteran appeared to "tear up," though he would never admit to any profound feeling of depression. The Veteran denied paranoid ideation, and similarly denied any ritualistic behaviors. However, he did describe what appeared to be panic attacks without agoraphobia. Significantly, the Veteran did not describe any delusional thought content. Nor was there any evidence of ideas of reference. The Veteran's judgment for hypothetical situations was considered to be intact, and his insight into his current life situation was apparent. Remote memory was similarly intact, as was short-term recall for three unrelated objects. The pertinent diagnoses noted were chronic posttraumatic stress disorder; panic disorder without agoraphobia; and alcohol dependence, in remission, with a Global Assessment of Functioning Score of 55. In the opinion of the examiner, a separate Global Assessment of Functioning Score could not be assigned for each of the Veteran's diagnoses. However, it was the professional opinion of the examiner that the Veteran's posttraumatic stress disorder and associated panic disorder accounted for the substance of the Veteran's Global Assessment of Functioning Score, as well as the Veteran's social and occupational dysfunction. Significantly, according to the examiner, the recorded diagnosis of bipolar disorder in the Veteran's medical record was not well-substantiated. Rather, the Veteran's psychiatric difficulties, including his insomnia, were best explained as manifestations of posttraumatic stress disorder stemming from his "combat zone fear" and an alleged episode of "horror and disgust" upon encountering a grim scene of death "with bodies stacked in a pile." In May 2003, the Veteran was referred for a psychological evaluation by the Disability Determination Section of the State of Tennessee. On mental status examination, the Veteran was well-oriented, and able to give an adequate response to very simple proverbs. However, more complex proverbs puzzled him. Memory was described as 2/3 at five minutes, though the Veteran's thought patterns overall were somewhat concrete and tangential. At the time of examination, the Veteran had some difficulty maintaining a logical and coherent train of thought. His affect was labile and slightly hostile, and his behavior characterized by almost constant fidgeting, vigilance, and scanning, with a noticeable startle reflex. Auditory and visual hallucinations, as well as olfactory hallucinations, were reported. According to the examiner, it was possible to establish rapport with the Veteran only with some difficulty. The Veteran's attention span was rated as fair to poor, and while he was responsive to questions, he often seemed "off in a world of his own." Speech was within normal limits and adequately articulated for understandability, though eye contact was quite variable. The pertinent diagnoses noted were severe recurrent major depression, with psychotic features; moderate to severe posttraumatic stress disorder; generalized anxiety disorder; and personality disorder, not otherwise specified, with a Global Assessment of Functioning Score of 35. On subsequent VA psychiatric examination in late September 2003, it was noted that the Veteran's claims folder, as well as electronic and paper medical records, and psychometric testing, including the Personality Assessment Inventory, were available, and had been reviewed. According to the examiner, at the time of the Veteran's first VA hospitalization during the months of May and June 1998, results of psychometric testing reflected a pattern of over reporting of psychopathological symptoms, resulting in a diagnosis of impulse control disorder, situational depression, and personality disorder, with well-defined anti-social personality features. Moreover, a psychological evaluation conducted in August 2001 showed that the Veteran had been filing for disability pension, and had no interest in returning to outside employment despite the fact that he was currently working in a compensated work therapy position which had outside employment as the stated goal. Found notable by the examiner was the fact that, while in the waiting area preceding his examination, the Veteran was observed to introduce himself to others in a pleasant and interpersonal manner. However, when beginning the examination, his mood and behavior appeared to shift. On mental status examination, the Veteran's grooming was neat. However, his mannerisms were characterized by restlessness and irritability. The Veteran's speech was fast in rate, with an aggressive tone. His relationship to the examiner was described as guarded, while the Veteran himself described his mood as "depressed, agitated, and confused," considered consistent with his overall affect. In general, the Veteran's affect was full ranged and labile. The Veteran was oriented to person, place, time, and situation, and while his intelligence was not formally tested, based on his history, educational achievement, and current language skills, it was estimated to be in the average range. At the time of examination, the Veteran did not reveal current suicidality or homicidality. However, he did present with reports of a depressed mood, which he described as "subjective depression for about three weeks solid every day." Anhedonia was similarly described, as was low self-esteem, a lack of energy, fatigue, decreased concentration, and decreased sleep. At the time of examination, the Veteran presented with reports of an anxious mood, as manifested by "anxious attacks," which he described as getting short of breath, with his heart "jumping out of his chest through his throat for 5 to 10 minutes," which reportedly occurred approximately once per week. The Veteran reported paranoid ideation, stating that he was constantly suspicious of others, though there was no evidence of any specific delusional beliefs. The Veteran did not manifest ritualistic behavior, though he did describe problems with panic attacks, none of which had been "clinically observed." The Veteran described impaired impulse control consisting of a loss of temper. However, his thought processes were logical, goal-directed, and coherent. When questioned, the Veteran reported visual hallucinations, as well as "horrid memories" of the "road of death" and the "smell of rotten bodies." His judgment appeared to be poor, and insight into his current life situation was not apparent. Attention and concentration appeared fair, and immediate memory was intact. Recent memory was described as fair, while remote memory was intact. According to the examiner, since last examined, the Veteran was administered the Personality Assessment Inventory in an attempt to identify symptoms and help in diagnostic evaluation. Results of this testing indicated that the primary impression was one of malingering, with an extremely negative evaluation of self and life, and some likely deliberate distortion of symptoms. On a scale designed to detect malingering, the Veteran scored higher than a sample of people instructed to malinger in order to "fake mental illness." Significantly, the score on this "malingering index" was highly unusual, and occurred only when severe mental disorder was being feigned. According to the examiner, this was consistent with psychometric testing conducted in 1998, which indicated the over reporting of symptoms and characterological problems. Significantly, review of testing conducted in March 1999 suggested that the Veteran did not meet the criteria for posttraumatic stress disorder at that time. Although he scored above the threshold on a posttraumatic stress disorder screening instrument, this was considered to be a "false positive," with the result that the Veteran was not diagnosed with posttraumatic stress disorder. Following examination, it was noted that, based on clinical findings, it appeared that the Veteran had a current diagnosis of malingering. Other diagnoses included bipolar disorder, not otherwise specified (to encompass the symptoms recognized in past hospitalizations, with depressive disorder, major depression, and bipolar disorder). An additional diagnosis noted was personality disorder, not otherwise specified, with anti-social and borderline features. At the time of examination, the Global Assessment of Functioning Score was 55. According to the examiner, the above diagnoses were based on a distorted and unreliable clinical picture, as evidenced by signs of malingering. While the Veteran did indicate impairment in both the social and vocational arenas, it was impossible for the examiner to adequately assess the degree of impairment due to apparent malingering present during the interview. In an addendum to the aforementioned VA psychiatric examination dated in mid-September 2004, the same psychiatric examiner who had conducted the September 2003 examination indicated that, since late September 2003, the Veteran had not received specialized mental health care, but was instead receiving mental health care through his primary care provider, consisting, for the most part, of medication. In the opinion of the examiner, the Veteran had not been able to articulate a clearly documented stressor, as required for a diagnosis of posttraumatic stress disorder. Significantly, according to the Veteran, while in service, he had served as a cook and mechanic, as well as "in transportation." The Veteran identified his stressor as seeing a "pile of dead bodies" while he was driving a truck, at which time he had to "pull over for approximately 20 minutes." Significantly, the Veteran did not identify responding with intense fear, helplessness, or horror to the aforementioned situation, one of the required criteria for a diagnosis of posttraumatic stress disorder. Moreover, clinical records failed to reveal a confirmed diagnosis of posttraumatic stress disorder, notwithstanding seven psychiatric hospitalizations. Significantly, an intake interview performed by staff at the posttraumatic stress disorder program in March 1999 failed to diagnose posttraumatic stress disorder. Rather, identified diagnoses included major depression, alcohol dependence in sustained partial remission, simple phobia by history, and personality disorder. Moreover, an additional psychological consult in August 2001 identified no psychiatric disability other than a personality disorder. Following a period of VA hospitalization in November 2004, the Veteran received diagnoses of bipolar disorder, depressed; and major depression, with a Global Assessment of Functioning Score at discharge of 60. Pursuant to applicable law and regulation, the 50 percent evaluation in effect prior to May 1, 2005 for the Veteran's service-connected posttraumatic stress disorder contemplates the presence of occupational and social impairment, with reduced reliability and productivity due to such symptoms as: a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). In contrast, a 70 percent evaluation requires demonstrated evidence of 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 activity; 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); and/or an inability to establish and maintain effective relationships. Id. Global Assessment of Functioning Scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), page 32]. A Global Assessment of Functioning Score of between 11 and 20 is defined as "some danger of hurting self or others (e.g. suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A Global Assessment of Functioning Score of between 21 and 30 is defined as "behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost areas (e.g., stays in bed all day; no job, home, or friends). A Global Assessment of Functioning Score of between 31 and 40 is defined as "some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A Global Assessment of Functioning Score of between 41 and 50 is defined as "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). A Global Assessment of Functioning Score of between 51 and 60 is denied as "moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A Global Assessment of Functioning Score of between 61 and 70 is defined as "some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships." While the Rating Schedule does indicate that the rating agency must be familiar with the Diagnostic & Statistical Manual of Mental Disorders, it does not assign disability percentages based solely on Global Assessment of Functioning Scores. See 38 C.F.R. § 4.130 (2012). Rather, Global Assessment of Functioning Scores are but one factor to be considered in conjunction with all other pertinent evidence of record. In light of the evidence, it is clear that, prior to May 1, 2005, no more than a 50 percent evaluation was warranted for the Veteran's posttraumatic stress disorder. Significantly, at no time during that period did the Veteran exhibit symptomatology consistent with a 70 percent evaluation, such as obsessional rituals which interfered with his routine activities; illogical, obscure, or irrelevant speech, near-continuous panic, or spatial disorientation. Rather, for the period in question, the Veteran was most often described as alert and well-oriented, with normal speech, tone and rate, and "socially appropriate." In fact, as recently as September 2003, the Veteran was described as having a "full ranged and labile affect," with "neat" grooming, and no evidence of any sucidality or homicidality. As noted above, not until the time of a VA psychiatric examination in April 2002 did the Veteran receive a diagnosis of post-traumatic stress disorder. Prior to that time, the Veteran had been given other psychiatric diagnoses, most notably, depression. Significantly, following a VA psychiatric examination in September 2003, it was determined that the Veteran did not, in fact, suffer from a posttraumatic stress disorder, but was rather malingering. Nonetheless, the Veteran has now once again been given a diagnosis of posttraumatic stress disorder. In any case, it is clear that, prior to May 1, 2005, at which time the Veteran's previous evaluation for posttraumatic stress disorder was reduced to zero percent, symptomatology attributable to that disability is consistent with no more than a 50 percent evaluation. Accordingly, an evaluation in excess of 50 percent for posttraumatic stress disorder prior to May 1, 2005 must be denied. Turning to the issue of entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder effective from May 2, 2012, the Board observes that, at the time of a recent VA psychiatric examination in May 2012, there was noted the presence of a depressed mood, as well as anxiety, panic attacks more than once a week, and chronic sleep impairment. Additionally noted were certain disturbances of motivation and mood, as well as difficulty in establishing and maintaining effective work and social relationships. The pertinent diagnoses noted were bipolar disorder, most recent episode mixed, severe, with psychotic features; and posttraumatic stress disorder. According to the examiner, the Veteran's symptoms of posttraumatic stress disorder appeared to be generally mild, which is to say, he "just met" the criteria for that diagnosis. While the Veteran described symptoms consistent with a diagnosis of posttraumatic stress disorder and bipolar disorder, certain symptoms (e.g., exaggerated startle response, physiological reactivity at exposure to triggers) were, in the opinion of the examiner, more likely attributable to posttraumatic stress disorder, as opposed to other symptoms (e.g., sad mood, pressured speech) which could be attributed to a mixed episode of bipolar disorder. Nonetheless, due to the overlapping of many symptoms (e.g., a lack of pleasure in activities, sleep problems), it was impossible to tease apart which specific symptoms were best accounted for by which diagnosis. According to the examiner, the Veteran's occupational and social impairment with regard to all mental disorders was best described as occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Global Assessment of Functioning Score at the time of examination was 60. Pursuant to applicable law and regulation, the 30 percent evaluation in effect from May 2, 2012 for the Veteran's service-connected posttraumatic stress disorder contemplates the presence of 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; and/or mild memory loss (such as forgetting names, directions, or recent events). A 50 percent evaluation, as noted above, contemplates the presence of occupational and social impairment, with reduced reliability and productivity due to such symptoms as: a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effect work and social relationships). 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). As is clear from the above, from May 2, 2012, the date of the aforementioned VA psychiatric examination, no more than a 30 percent evaluation is warranted for the Veteran's service-connected posttraumatic stress disorder. In that regard, and as noted above, as of the time of that examination, the Veteran was described as suffering from no more than "mild" posttraumatic stress disorder. In fact, according to the examiner, the Veteran "just met" the criteria for that diagnosis. Significantly, as of the time of that examination, the Veteran was felt to be suffering from occupational and social impairment, with only occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Moreover, there currently exists no evidence that, as of May 2, 2012, the Veteran was suffering from symptomatology sufficient to warrant the assignment of a 50 percent evaluation, such as a flattened affect; circumstantial, circumlocutory, or stereotyped speech; or difficulty in understanding complex commands. Accordingly, an evaluation in excess of 30 percent for posttraumatic stress disorder effective from May 2, 2012 is not warranted. Moreover, based on a review of the entire evidence of record for the periods in question, the Board is of the opinion that the disability picture presented by the Veteran's service-connected posttraumatic stress disorder is appropriately contemplated by the Rating Schedule, and that referral for consideration of an extraschedular evaluation is, therefore, not in order. See Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). ORDER Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder prior to May 1, 2005 is denied. Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder from May 2, 2012 is denied. REMAND In addition to the above, the Veteran seeks entitlement to a compensable evaluation for service-connected posttraumatic stress disorder during the period from May 1, 2005 to May 2, 2012. However, a review of the record raises some question as to the severity of the Veteran's service-connected posttraumatic stress disorder during that particular period in time. In that regard, and as noted above, at the time of a VA psychiatric examination in April 2002, it was, for the first time, determined that the Veteran did, in fact, suffer from a posttraumatic stress disorder related to his service in the Persian Gulf War. This conclusion was reached notwithstanding the fact that, on various previous occasions, the Veteran was felt to be "over reporting" his psychiatric symptomatology, and, in fact, possibly malingering. Significantly, as of the time of a subsequent VA psychiatric examination in September 2003, it was the conclusion of the examiner that the Veteran did not, in fact, suffer from a posttraumatic stress disorder, and that his current diagnosis was one of "malingering." Moreover, on the basis of that examination, the Veteran's previous 50 percent evaluation for service-connected posttraumatic stress disorder was reduced to zero percent, effective May 1, 2005. What remains at issue is whether, during the period from May 1, 2005 to May 2, 2012, (at which time, as noted above, the Veteran was assigned a 30 percent evaluation for posttraumatic stress disorder), a greater than noncompensable evaluation was warranted for the Veteran's posttraumatic stress disorder. In that regard, a review of the record discloses that, during the period in question, the Veteran received diagnoses not only of posttraumatic stress disorder, but also of severe mixed bipolar disorder with psychotic features, major depression, alcohol dependence, personality disorder traits, and a mood disorder. What must be determined is the extent to which symptomatology present during the period in question represented the severity of the Veteran's posttraumatic stress disorder, as opposed to symptomatology related to his other, nonservice-connected psychiatric disabilities. Under the circumstances, the Board is of the opinion that further development of the evidence is necessary prior to a final adjudication of the Veteran's claim for increase. Accordingly, the case is REMANDED to the RO for the following action: 1. The Veteran's entire claims folder should be furnished to a VA psychiatrist who has not heretofore seen, examined, or treated the Veteran. Following a review of the Veteran's entire claims folder, and, in particular, the period extending from May 1, 2005 to May 2, 2012, the evaluating psychiatrist should, to the extent possible, determine what, if any, portion of psychiatric symptomatology present during the period from May 1, 2005 to May 2, 2012 was directly attributable to the Veteran's service-connected posttraumatic stress disorder, as opposed to his other, nonservice-connected psychiatric disabilities. Should it prove impossible to "separate out" symptomatology directly attributable to posttraumatic stress disorder, as opposed to the Veteran's other psychiatric disabilities, the evaluating psychiatrist should specifically so state. Following the above examination of the evidence, the evaluating psychiatrist should choose which of the following descriptions best summarizes the level of occupational and social impairment directly attributable to the Veteran's service-connected posttraumatic stress disorder during the period from May 1, 2005 to May 2, 2012: a. A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication; b. Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication; c. Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation; d. Occupational and social impairment with reduced reliability and productivity; e. Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood; f. Total occupational and social impairment. A complete rationale must be provided for any opinion offered, and all information and opinions, once obtained, must be made a part of the Veteran's claims folder. 2. The RO should then review the aforementioned report to ensure that it is in complete compliance with the directives of this REMAND, and that the evaluating psychiatrist has documented his consideration of all pertinent evidence of record. If the report is deficient in any manner, the RO must implement corrective procedures at once. 3. The RO should then readjudicate the claim regarding whether the Veteran is entitled to a greater than noncompensable evaluation for service-connected posttraumatic stress disorder for the period from May 1, 2005 to May 2, 2012. Should the benefit sought on appeal remain denied, the Veteran and his attorney should be provided with a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant action taken on the claim for benefits since the issuance of the most recent SSOC in November 2012. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or 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. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs