Citation Nr: 1329129 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 03-32 221 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a skin disorder (claimed as jungle rot), to include as due to in-service herbicide exposure. 2. Entitlement to service connection for a low back disorder, to include as due to the service-connected residuals of a pilonidal cyst. 3. Entitlement to an initial disability rating greater than 50 percent prior to February 27, 2012, and in excess of 70 percent thereafter, for service-connected posttraumatic stress disorder (PTSD) with depressive disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The Veteran had active military service from April 1968 to April 1972, including a tour in the Republic of Vietnam. The Veteran's skin and lumbar spine claims come before the Board of Veterans' Appeals (Board) on appeal from an October 2002 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's PTSD claim comes before the Board on appeal from a September 2004 rating decision, which granted the Veteran's claim of service connection for PTSD and assigned a 50 percent disability rating, effective October 29, 2003. These matters were previously before the Board in January 2009 and September 2011, and remanded to the RO for additional development and adjudication. An interim, November 2012, rating decision increased the Veteran's rating for PTSD to 70 percent, effective February 27, 2012; and granted a TDIU rating, also effective February 27, 2012. Consequently, the matter of a TDIU rating is no longer before the Board. In his October 2003 Substantive Appeal (on VA Form 9), the Veteran requested a Board hearing before a Veterans Law Judge (VLJ). However, in a November 2003 statement, the Veteran withdrew his hearing request. Thus, his hearing request is considered withdrawn. 38 C.F.R. § 20.704(e) (2012). As to the claims for skin and low back disabilities, the September 2011 remand orders were not complied with, and thus, further remand is mandated. Stegall v. West, 11 Vet. App. 268 (1998). These claims are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the period prior to November 2, 2006, the Veteran's PTSD has not been manifested by 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 work like setting); inability to establish and maintain effective relationships. 2. For the period beginning November 2, 2006 thru February 27, 2012, the Veteran's PTSD has resulted in occupational and social impairment with deficiencies in most areas due to severe symptoms, such as panic attacks, depression and impaired impulse control, including unprovoked irritability and the inability to function appropriately or effectively, which have resulted in the Veteran being unable to establish and maintain effective relationships; his PTSD is not productive of total occupational and social impairment. 3. For the period beginning February 27, 2012, the Veteran's PTSD has not been manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to November 2, 2006, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. For the period beginning November 2, 2006, the criteria for a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 3. For the period beginning February 27, 2012, the criteria for a disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant and his representative of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a), 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify The record shows that in a November 2003 VCAA notice letter, the Veteran was informed of the information and evidence necessary to warrant entitlement to the benefit sought on appeal. The Veteran was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C.A. § 5103(a , must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In this case, the RO provided VCAA notice to the Veteran in November 2003, which was prior to the September 2004 rating decision. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. Further, the notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the Veteran was provided with notice of what type of information and evidence was needed to substantiate the claim for service connection. Further, the November 2003 letter also gave notice of the types of evidence necessary to establish a disability rating and effective date for the disability on appeal. The Veteran's claim on appeal arises from his disagreement with the initial disability evaluation assigned following the grant of service connection. The Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes all identified medical records, Vet Center treatment records, and Social Security Administration (SSA) records. The Veteran was afforded VA examinations in April 2004, March 2008, February 2012, and September 2012. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. Legal Criteria The Board notes that is has reviewed all of the evidence in the Veteran's claims file, as well as in "Virtual VA" (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000)(VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The present appeal involves the Veteran's claim that the severity of his service-connected PTSD warrants a higher disability rating. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Under the criteria for PTSD (set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411), a 30 percent rating is assigned 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). A 50 percent rating is assigned for occupational and social impairment, with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when there is 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. A 100 percent schedular rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relative, own occupation or own name. The Board notes here that the symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown , 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF score between 41 and 50 is indicative of 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 GAF score between 51 and 60 is indicative of 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 coworkers); a GAF between 61 and 70 is indicative of 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, has some meaningful interpersonal relationships. Factual Background The Veteran began counseling sessions at a Vet Center in 2003. At intake, the Veteran presented with anger, often at nothing, and depression. The initial evaluation noted symptoms to include, disorganized thoughts, poor appetite, sleep disturbance, suicidal thoughts (most recently in the 1980s), and homicidal thoughts with provocation. The Vet Center counselor assessed the Veteran with PTSD. In August 2003, he began individual counseling sessions. During the sessions between August and November 2003, the counselor noted the Veteran was very angry; very verbal, but without focus; stressed with regard to his finances; highly anxious and agitated; and very negative about the world and how mistreated he and his were. In January 2004, the Veteran was referred to a VA medical center (VAMC) for a psychiatric evaluation. The Veteran presented with PTSD, anger, irritability, and nightmares. Nightmares included dreams of battle, gunners in helicopters, and fighting. The Veteran reported he had pushed his wife out of bed during one of these nightmares. On examination, the Veteran reported some incidents of violence, homicidal ideation in regards to his son-in-law, suicidal ideation 30 years prior, and a history of self-destructive acts. The examiner noted the Veteran was rough appearing, casually dressed with a beard and was somewhat overweight. His attitude was hostile, and at times angry. His interaction with the examiner was noted as appropriate. His mood was noted as dysphoric, irritable, angry, unhappy, and concerned with losing control. His motivation and energy levels were fair, his concentration was good. The examiner noted his thought process was intact and he was fully oriented. The examiner also noted that the Veteran's memory was intact, and that he had excellent recall of past events. His cognitive function was good; his judgment and insight were intact. The Veteran did not report hallucinations or delusions. No obsessive symptoms were identified. It was noted the Veteran lacked tolerance, he was short tempered, and viewed life as black and white. Sleep patterns were very erratic due to nightmares. Other symptoms exhibited by the Veteran included flashbacks, déjà vu, and traumatic memories triggered by landscapes, pictures, or loud noises. It was also noted the Veteran did not like to be around people; he sometimes had the urge to fight them. The Veteran's GAF score was 55. In January 2004, the Veteran reported attending courses at the local community college through the Vocational Rehabilitation program. In March 2004, the Veteran was seen by the VAMC Mental Health Clinic (MHC). Treatment records showed that he was oriented, alert, euthymic, and had an appropriate affect, which was at times angry. He reported the intensity of the dreams and memories had diminished. His GAF score was 55. The Veteran underwent a VA examination in April 2004. The examiner noted he reviewed the Veteran's claims file, and previous treatment history from the VAMC and Vet Center. The Veteran reported he occasionally slept on the couch after nearly attacking his wife in his sleep. He reported that he was unable to sleep more than 2 to 3 hours. He expressed that he did not like to be around people. The examiner noted the Veteran had a stable marriage (27 years), and a history of work with stability, however at the time of the examination, the Veteran reported difficulties getting along with his bosses. The examiner noted the Veteran was tangential and circumstantial. Delusions and hallucination were denied. The Veteran's eye contact during the examination was poor. No suicidal ideations were reported; however the Veteran stated he had homicidal thoughts toward his son-in-law. The examiner noted the Veteran was able to maintain his own hygiene, was overweight, and appeared somewhat disheveled. Memory and orientation were noted as good. Some obsessive thoughts and ritualistic behaviors were identified. The Veteran reported feeling depressed with feelings of worthlessness, helplessness, hopelessness, and uselessness. The examiner noted his mood was dysphoric and angry at times. He was noted to be defensive. The examiner reported the Veteran's thought process was disorganized at times; his cognitive functioning and general knowledge was intact; his judgment and executive functioning were intact; but his insight was minimally impaired. The Veteran's GAF score was 55. In April 2004, a mental health treatment plan was initiated by the MHC, which included medication, individual psychotherapy every 6 to 8 weeks at the VAMC, and group PTSD sessions at the Vet Center. During his individual session of the same date, the Veteran's GAF score was noted to be 55. The Veteran noted his nightmares were less intense. The treating psychiatrist noted he appeared calmer, talkative, and showed more openness. It was also noted he was coping relatively well while attending college. During a June 2004 individual session, the Veteran presented with nightmares and waking in cold sweats. The psychiatrist noted he had no noticeable depression but had an intense affect with underlying hostility. A treatment record from July 2004 noted the Veteran's sleep improved with medication. His GAF score was 55. Vet Center notes from January 2004 to November 2004 detailed that the Veteran was engaged in his courses through the community college and had the goal of becoming a counselor. However, in November 2004, the Veteran began to express frustration with college, and in December 2004, he detailed various school related stressors. In February 2005, the Veteran presented at the VA MHC somewhat high strung with excitable mood and irritability. The Veteran reported nightmares, but that the slept well with medication. His GAF score was 55. It was recommended he continue the medication and attend individual treatment sessions every two months. Additionally, during Vet Center session, the Veteran noted falling behind in classes. In March 2005, the Veteran expressed concern that his academic program director was attempting to "weed him out" of the counseling program because of his PTSD and potential triggers. (The Vet Center counsel opined that it was his view that the Veteran was less suited to be a counsel because of his rigid, concrete, black and white view of the world, and his limited ability to empathize and limited insight to his own rigidity). In April 2005, the Veteran reported he was generally doing okay, but had a conflict with his wife and conflicts with his teachers. His GAF score was 55. In May 2005, VA received correspondence from the Veteran's college academic advisor and program instructor. The instructor noted the Veteran had the intellectual capacity for success in the program he was enrolled, however, he had difficulty working to deadlines, competing assignments, and attending classes. The instructor further stated that the Veteran seemed confused regarding assignments, disorganized, and preoccupied. The instructor concluded the Veteran's level of functioning was causing impairment in school and on social performance. The instructor expressed concerns whether the Veteran would be able to work in a less structured environment. A June 2005 MHC treatment note showed the Veteran was having difficulty in school, and expressed he was very upset, ready to fight with his teacher, and refused to take classes with that teacher. The psychiatrist noted he was alert and very irritable with the fear of losing control of his temper. The Veteran reported erratic sleep with periodic nightmares. The psychiatrist noted he was very sensitive to events in his life, highly frustrated, and without tolerance. His GAF score was 50, with a notation that the Veteran's GAF rating at best of functioning was 55, but generally was at 50. The psychiatrist questioned whether the Veteran could work with people. Medication was continued. In June 2005, the Veteran's mental health treatment plan was reviewed with the objective to reduce the intensity and frequency of his nightmares and to instruct him how to act appropriately with anger. Medication management and cognitive support therapy every 3 months were recommended. The psychiatrist noted there was no change in the Veteran's mental status since last session; his GAF score was 50. In August 2005, the VA psychiatrist noted there was not much change in his dysphoric, irritable mood, or with his lack of patience or frustration. His GAF score was noted at 55. Again in October 2005, it was noted the Veteran had problems with tolerance and patience. The VA psychiatrist noted he had a chronic critical attitude, but over-all was coping with his college courses, even though he had conflicts with certain teachers and instructions. In a December 2005, the Veteran presented with annoyances, irritability, and a contentious attitude. He reported that high stress brings back the nightmares. His GAF score was 55. In September 2005, the Veteran applied for a practicum position with the Vet Center, and was denied because of his lack of clinical training. A November 2005 Vet Center note showed the Veteran had attended 41 individual sessions and 55 group sessions before discontinuing counseling. The counselor noted that the Veteran stopped attending after being denied a practicum position. The Veteran resumed counseling in December 2005, but was again denied a counseling position at the Vet Center. A new MHC treatment plan was considered in March 2006. It was noted the Veteran experienced nightmares, was hypervigilant, always on guard, distrusting, and defensive. Also, smells, noises and rain triggered memories. The Veteran reported he was uneasy around groups of strangers. It was noted the Veteran had significant problems with anger. Additionally, it was noted that over the past year, there was no change in GAF scores (55). Medication management, along with both individual therapy and group PTSD sessions were continued. In June 2006, the Veteran's academic advisor again voiced concerns regarding the Veteran's ability to complete his studies. Specifically, the advisor noted that the Veteran's reactions to life circumstances have prevented him from having regular attendance, completing assignments, and participating appropriately in class. During an August 2006 MHC session, the Veteran reported a number of crises since the last session. The psychiatrist noted he was very tense, irritable, short tempered, and that he reported only sleeping 2 to 3 hours due to nightmares and sweating episodes. His GAF score was 55 with a note that he has serious problems relating to others and is often in conflicts with people of authority. During a September 2006 Vet Center session, the Veteran reported additional problems with schooling, which included failing one class and either failing or not understating another. This same month, he was seen at the VAMC after failing two courses in college and spoke of feelings of anger and revenge. No change in mental status was reported. At the November 2006 MHC session, the Veteran reported losing his educational support (Chapter 31 benefits were terminated). He appeared angry, critical, and short tempered. He reported periodic nightmares. His GAF score was 55. In December 2006, the Veteran was noted to have chronic issues with anger; his GAF score was reduced to 50. In November 2006, the Social Security Administration (SSA) determined that the Veteran had the residual functional capacity to perform light work activity that does not involve close interaction with co-workers or the general public. SSA found he had moderate difficulties in maintaining social functioning, and mild difficulties in maintaining concentration, persistence or pace. The Veteran was found to be disabled for SSA purposes beginning December 31, 2003 as a result of his PTSD and degenerative disc disease of the back. At a March 2007 MHC session, the Veteran was noted to be dysphoric, anxious, verbal, and presented issues with poor frustration tolerance, loss of temper, and a strong critical nature. His GAF score was 50. In June 2007, the Veteran's treatment plan was again reassessed. The most prominent issues identified were nightmares and anger. Medication and brief supportive/cognitive therapy were recommended. A VA examination was conducted in March 2008. The examiner noted that the claims file and VAMC treatment records were reviewed, and a two hour interview with the Veteran was done. On examination, the Veteran expressed frustration and anger with many situations in life, including his wife's healthy, his absent son-in-law, and his physical ailments. The Veteran reported he experienced nightmares, flashbacks, and intrusive distressing thoughts on an increased frequency when he was feeling stressed or with specific triggers. He reported nightmares two to three night in a row on a weekly basis, and would awaken disoriented or with increased heart rate or sweating. He reported conducting perimeter checks of his property, with an unidentified weapon. Flashbacks or intrusive thoughts were triggered by dates, sudden loud noises, or smells. The Veteran reported he avoids talking about his service outside the group sessions. He reported he avoids fireworks and seafood. The examiner noted the Veteran has social relationships with his immediate family and other Veterans. The examiner noted the Veteran had significant difficulty with anger and irritability. The Veteran denied suicidal ideation, but stated he was homicidal, but without any particular intent to harm. The examiner noted the Veteran was alert and fully oriented, maintained good eye contact, and was cooperative. His affect was reported as restricted to sarcasm, irritability, frustration, and anger; using swear words, name-calling, and blame. On examination, the Veteran denied paranoia or hallucinations. His concentrations and memory were grossly intact. The examiner noted the Veteran's insight and judgment were good and he was not felt to be a danger to himself or others. His GAF score was 55. The examiner noted that there was minimal changes in presentation since the April 2004 VA examination. In November 2008, the Veteran's treating psychiatrist at the VAMC changed. As a result of this change, the Veteran attended counseling sessions every three months from November 2008 through May 2010. No new symptoms were reported during this time; the Veteran continued to report nightmares and flashbacks. His attitude continued to exhibit as angry and irritable. His GAF scores were not reported on the MHC treatment records during this time. In June 2010, the Veteran returned to the MHC with anger and homicidal ideation, but was able to restrain himself. He reported daily flashbacks, and experiencing intrusive memories of comeback and decomposing corpses. The psychiatrist noted the Veteran was cooperative, reasoning, alert and attentive. Grooming was noted as appropriate. The Veteran's affect was angry; his thought process normal and coherent. The psychiatrist noted his judgment was impulsive. His GAF score was 49. Following this, the Veteran was seen bi-monthly, without additional PTSD symptoms. His GAF scored remained at 52. In January 2011, the Veteran presented more irritated and depressed, and reported being burdened by multiple stressors, including health, marital issues and an ill pet. No new symptoms were reported, although his judgment was noted to be impulsive. His GAF score was 50. The Veteran continued to be seen bi-monthly, with the same complaints and symptoms. His GAF score increased to 54. In September 2011, a MCH treatment record showed the Veteran operating at baseline. He was noted to be irritable but rationale. The psychiatrist reported the Veteran had suicidal ideation without a specific plan. His GAF score was 54. The Veteran underwent a VA examination in February 2012. Following a review of the claims file, treatment records, previous VA examinations , and a 90 minute interview, the examiner confirmed the Veteran had an Axis I diagnosis of PTSD, and concluded that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. During the interview, the Veteran stated he lived with his wife, daughter, and granddaughter, but had not contact with other family members and related that he has only one friend who he is close with. The Veteran reported he was no longer involved in social activities. The examiner noted the Veteran last worked in 2002 due to difficulties with his supervisor. The Veteran reported he went back to school to be a counselor at the Vet Center, but due to conflicts with a teacher at the school and the staff at the Vet Center, he did not earn his certificate. The examiner noted the Veteran has had difficulty getting along with others for many years, to include being fired from jobs due to verbal discord. Symptoms of the Veteran's PTSD include: depressed mood; anxiety; suspiciousness; panic attacks occurring more than once a week; chronic sleep impairment; circumstantial, circumlocutory or stereotyped speech; disturbances of motivation and mood; difficulty establishing and maintaining effective work and social relationships; obsessional rituals which interfere with routine activities; and neglect of personal appearance or hygiene. The Veteran reported ongoing nightmares, panic attacks when he wakes up, and flashbacks about Vietnam. The examiner observed that the Veteran was irritable, tangential, and circumstantial. He had sunglasses on during the entire interview and related he had a "nuclear headache". The Veteran was noted to have poor grooming and hygiene and related that he was unable to shower because water would aggravate his jungle rot. The Veteran reported ongoing conflicts with others throughout his life since returning from Vietnam, to include supervisors and co-workers, and homicidal ideations without current intent or plan. The examiner noted the Veteran stated he spent 70 percent of his day thinking about his experiences in Vietnam and how he was treated. A clarification to the February 2012 VA examination was prepared in September 2012. This opinion was sought to clarify the Veteran's diagnosis of depression. The clarification stated that the Veteran reported that his PTSD symptoms and depressive symptoms shared the same time of onset, which was following discharge from a hospital in 1970. The examiner noted the Veteran described a process whereby his PTSD symptoms led to eventual depression, and denied depression before his military service. Therefore, the examiner noted that it was at least as likely as not that the Veteran's depression was secondary to his PTSD. However, the examiner opined that the Veteran's depression was inextricably intertwined with his PTSD, and it was difficult to parse out the specific symptoms attributable to each disorder, as there was considerable overlap between the two. The examiner delineated the symptoms specific to each disorder. With regard to PTSD, the examiner noted the Veteran's symptoms included nightmares, flashbacks, intrusive thoughts, suspiciousness, panic attacks upon awakening from sleep, physiological and psychological reactivity in response to triggers, a significant amount of time spent engaging in perimeter checks, hypervigilance, occasional startle response, restricted range of affect, detachment from other people, avoidance of thought of defeat in Vietnam, and angry/aggressive outbursts. With regard to depression, the examiner noted the Veteran's symptoms included, helplessness, emotion distress originating as sadness and transforming to anger, low energy, low motivation, and poor appetite. With regard to symptoms that overlap, the examiner noted the Veteran's overlapping symptoms included poor sleep, poor concentration, low frustration tolerance, and decreased participation in important activities. The Veteran's course of treatment included individual and group sessions at the Vet Center. Sessions began in 2003 and continued through 2009, with some gaps in attendance (especially after the Veteran quit attending sessions following his failed application to be a counselor at the Vet Center). In December 2008, a summary of his sessions was provided. The counselor noted the Veteran did not care about his appearance and that he seldom bathed because he explained it would irritate his jungle rot. The counselor noted the Veteran smelt very strongly of cigarette smoke. The Veteran's counselor reported that the Veteran responded to each topic of conversation with a dire story or a complaint, and when frustrated or confronted, he responded that the confronting individual should be shot or disposed of. It was noted that the Veteran acknowledged that it was very hard for him to tolerate a supervisor that he perceived as being less knowledgeable or competent. The counselor noted the Veteran experienced disturbing memories, disturbing dreams, feeling cut off from people, trouble falling asleep, angry outbursts, and was super alert. Other symptoms identified during his course of treatment at the Vet Center are identical to those identified and discussed during his treatment at the VAMC MHC. Analysis Prior to November 2, 2006 When considering the impact of the Veteran's symptoms on his overall occupational and social impairment, the Board finds that prior to November 2, 2006, the Veteran's PTSD manifested by symptoms that more closely fit the criteria for a 50 percent disability rating than those for the next higher rating of 70 percent. The Veteran's most prominent manifestations of his PTSD include anger, irritability and negativity. However, prior to November 2, 2006, these manifestations did not result in significant occupational and social impairment. Prior to November 2, 2006, the Veteran was enrolled in courses at the local community college through the vocational rehabilitation program with the goal of becoming a counselor. Early on, the Veteran reported doing well in his course and showed enthusiasm for what he was doing. It was not until 2005 that the Veteran showed reduced reliability and productivity when he began to experience conflicts with his teachers, began missing assignments, and showed an inability to deal with school related stressors. However, even with these difficulties, the Veteran remained in school and focused on becoming a counselor. Additionally, the Veteran was able to establish and maintain effective work and social relationships. Even though the Veteran reported that he disliked being around people, on VA examination in 2004, the examiner noted the Veteran had a stable marriage and a history of work stability. During Vet Center group sessions, the Veteran fully participated and interacted with other Veterans. During this time period, the Veteran was always noted to have good concentration, excellent memory, and even though he sometimes exhibited disorganized or irrelevant thoughts, his cognitive function was good. Some obsessive and ritualistic behaviors were identified, but interference with regular activities was not reported. Additionally, although the Veteran was angry, irritable, and at times hostile, VA treatment notes and examination reports show the Veteran's interaction with treatment professionals was appropriate. Judgment and insight were noted as not showing impairment. There was no spatial disorientation reported. No noticeable depression was shown on examinations. Additionally, the evidence does not show that the Veteran experienced near-continuous panic attacks. While the Veteran experienced nightmares and erratic sleep, these were regulated by medication. The Board notes that the Veteran's GAF score w as most often at 55, which is indicative of moderate symptoms. Based on the evidence above, deficiencies in most areas (work, school, family, social, mood) were not shown as to warrant a 70 percent rating. In summary, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against entitlement to a rating in excess of 50 percent for the Veteran's PTSD prior to November 2, 2006. As the preponderance of the evidence is against an increase, the benefit of the doubt rule is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. From November 2, 2006 to February 27, 2012 Although the evidence is not compelling, it does appear that a question arises as to whether the PTSD increased in severity so as to more nearly approximate the criteria for a 70 percent rating beginning around November 2006. The Board believes it of some significance that on November 2, 2006, the Veteran reported losing his educational benefits. It appears that his PTSD impairment was the reason of his inability to finish course work, attend class, and participate appropriately in class. As a result, the Veteran failed a number of courses and was unable to obtain a counseling certificate. In addition, his response to such failure was inappropriate and was indicative of impulsive judgment, including the desire to fight the teacher who failed him, feelings of revenge, and failing to attend Vet Center counseling sessions because he was denied a position as a counselor. While the Veteran's PTSD was always manifested by anger and irritability, his affect was now reported as restricted to sarcasm, irritability, frustration, and anger. During this time, treatment records showed the Veteran progressively became more depressed and anxious. Additionally, the Veteran exhibited near continuous anger and hostility. Initially, the Veteran reported occasional nightmares or flashbacks. By 2008, he reported nightmares or flashbacks 2 to 3 nights per weeks; in 2010, daily flashbacks were reported; and on 2012 examination, the Veteran reported thinking about Vietnam and his experiences 70 percent of the day. In September 2011, for the first time in 30 years, the Veteran was noted as having suicidal ideation, but without a specific plan. Since November 2, 2006, the Veteran's GAF scores fluctuated between 49 and 54, which indicates moderate to serious symptoms and moderate to serious impairments in social, occupational, or school functioning. The Board finds the increased manifestations of the Veteran's PTSD led to deficiencies in the Veteran's ability to attend school and work, his judgment, thinking, and mood; and therefore finds that the criteria for a 70 percent rating were met effective November 2, 2006. From February 27, 2012 The RO increased the PTSD rating to 70 percent effective February 27, 2012. The Board agrees with this determination for the reasons stated above. To meet the criteria for a 100 percent disability rating, the resulting PTSD disability picture must more nearly approximate total occupational and social impairment, due to symptoms such as: gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. The Board is unable to find that the criteria for a 100 percent rating were met at any time during the appeal. There is no evidence that the Veteran suffers from symptoms of grossly inappropriate behavior. The Veteran has continuously denied delusions or hallucinations. At no time has the Veteran shown to be a danger to himself or others; even though he persistently expressed homicidal thoughts in relation to his son-in-law, they were without intent or plan. Additionally, although the Veteran expressed suicidal ideation in 2011, it was without specific plan. Although one of the criteria for a 100 percent rating is poor hygiene, it requires the Veteran to be unable to perform maintenance of personal hygiene. This is not the case in this instance, as the Veteran is capable of maintaining his personal hygiene, he solely chooses not to bath to prevent irritating his skin. Additionally, while the Veteran indicated he is withdrawn from people and is no longer engaged in social activities, he remained married and maintained a relationship with his daughter and grandchild, as well as socialized with a friend and members of his PTSD group. A 100 percent rating is also not applicable because the Veteran has not been shown to be disoriented to time or place, and there is no indication that he is unaware of his own name or the names of others. The Board is cognizant that the Veteran has a significant level of impairment due to his PTSD symptoms, which has been recognized by the assignment of a 70 percent rating. However, the Board is bound to apply the regulatory criteria for rating PTSD, and for the reasons set for above the Board finds that the preponderance of the evidence is against assignment of a rating in excess of 70 percent. As the preponderance of the evidence is against an increase, the benefit of the doubt rule is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate a Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether a Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the symptoms described by the Veteran fit squarely within the criteria found in the relevant Diagnostic Codes for the disability at issue. In short, the rating criteria contemplate not only his symptoms but the severity of his disability. For these reasons, referral for extraschedular consideration is not warranted. ORDER The appeal is granted in part and denied in part as follows, subject to the law and regulations governing payment of VA monetary benefits. Prior to November 2, 2006, entitlement to a rating in excess of 50 percent for PTSD is not warranted. A 70 percent rating, but no higher, is warranted for PTSD from November 2, 2006. Entitlement to a rating in excess of 70 percent from February 27, 2012 is not warranted. REMAND As noted in the Introduction, the claims for skin and low back disabilities were previously before the Board in January 2009 and September 2011. At that time, the Board determined that additional evidentiary development was necessary. As the remand orders of the Board were not complied with, further remand is mandated. Stegall, supra. Specifically, pursuant to the Board's September 2011 remand, the Veteran was to be scheduled for VA examinations to determine the nature, extent, and etiology of his skin and low back disabilities. Examinations were conducted in February 2012. The Board has reviewed the examination report and finds the opinions and rationales provided wholly inadequate for adjudication purposes. The opinion failed to address the questions asked by the September 2011 remand, and failed to address the Veteran's contentions, which are the crux of the appeal. As such, the Board finds the February 2012 examination inadequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). These matters must be returned to the RO for additional examinations. Accordingly, the case is REMANDED for the following action: 1. Obtain updated VA treatment records from January 2012 to the present. 2. Schedule the Veteran for a VA examination to ascertain the etiology of his currently diagnosed rash, skin disorder, and basal cell carcinoma of the skin (as diagnosed in VAMC treatment records). All indicated studies and tests should be accomplished, and all clinical findings should be reported in detail. The claims folder must be provided to the examiner for review in conjunction with the examination. The examiner should respond to the following: a) Please identify all skin disabilities, to include consideration of all skin disabilities reflected in VAMC treatment records; b) Is it at least as likely as not (50 percent probability or more) that any current diagnosed skin disorder, or any skin disorder documented in VAMC treatment records, is causally related to his active military service, to include as due to the May 1971 report of a rash and/or the January 1972 report of skin irritation from an in-grown hair; c) Is it at least as likely as not (50 percent probability or more) that a current skin disability, or any skin disorder documented in VAMC treatment records, is causally related to presumed in-service herbicide exposure. The examiner should reconcile any opinion with the service treatment records, post-service treatment records, and the Veteran's lay statements. The examiner should provide a rationale for all opinions. 3. Schedule the Veteran for a VA examination to ascertain the etiology of his low back disability. All indicated studies and tests should be accomplished, and all clinical findings should be reported in detail. The claims folder must be provided to the examiner for review in conjunction with the examination. The examiner should respond to the following: a) Please identify all disabilities associated with the Veteran's back/lumbar spine; b) Is it at least as likely as not (50 percent probability or more) that any current diagnosed back disability is causally related to his active military service, to include the April 1969 motorcycle accident; c) Is it at least as likely as not (50 percent probability or more) that any current diagnosed back disability is proximately due to residuals of a pilonidal cyst; d) Is it at least as likely as not (50 percent probability or more) that any current diagnosed back disability is aggravated by residuals of a pilonidal cyst. The examiner should reconcile any opinion with the service treatment records, post-service treatment records, and the Veteran's lay statements. The examiner should provide a rationale for all opinions. 4. In the interest of avoiding future remand, the RO should then review the examination reports to ensure that the above questions have been clearly answered and a rationale furnished for all opinions. If not, appropriate action should be taken to remedy any such deficiencies in the examination reports. 5. Following completion of the above, and any other necessary development, the issues on appeal should be readjudicated. The Veteran and his representative should be provided with a supplemental statement of the case and afforded the appropriate opportunity to respond thereto. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Veteran 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. 2012). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs