Citation Nr: 1617243 Decision Date: 04/29/16 Archive Date: 05/26/16 DOCKET NO. 12-24 275 DATE APR 29 2016 On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, other than pain disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 30 percent for pain disorder. REPRESENTATION Appellant represented by: Stacey P. Clark, Attorney ATTORNEY FOR THE BOARD C. Jones, Associate Counsel INTRODUCTION The Veteran had active military service from April 1987 to June 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied service connection for PTSD and entitlement to an increased rating for the appellant's service-connected pain disorder. In a January 2012 decision, the Board recharacterized the issue of entitlement service connection for PTSD as stated on the title page. Additionally, the Board, in pertinent part, remanded the issues of entitlement to service connection for a psychiatric disorder and entitlement to an increased rating for pain syndrome for further development. Subsequently, in a September 2015 decision, the Board, in relevant part, denied entitlement to service connection for a psychiatric disorder, other than pain disorder and entitlement to a rating in excess of 30 percent for pain disorder. The Board notes that in the September 2015 decision, the issues of entitlement to increased ratings for chronic low back pain with degenerative disc disease and right left radiculopathy and entitlement to a total disability rating were remanded for additional development. As the claims were not adjudicated on the merits, that portion of the Board's decision is not vacated. ORDER TO VACATE An appellate decision may be vacated by the Board at any time upon the request of the appellant or her representative, or on the Board's own motion, when there has been a denial of due process. 38 C.F.R. § 20.904(a) (2015). In the appellant's Motion for Reconsideration received in January 2016, the Veteran's representative argued, in part, that relevant VA treatment records had not been obtained prior to the Board's decision. Here, the Board finds that its consideration of the appellant's claims of entitlement to service connection for a psychiatric disorder, other than pain disorder and entitlement to a rating in excess of 30 percent for pain disorder was based on an incomplete discussion of the record, specifically insofar as pertinent medical evidence was not associated with the claims file at the time of the Board's decision, and that the appellant was therefore not afforded full due process of law. Such evidence, being VA records, was constructively in VA's possession at the time of the Board denial. Accordingly, the portion of the Board's September 2015 that denied service connection for a psychiatric disorder other than pain disorder and entitlement to an increased rating for pain disorder decision is hereby vacated, and a new decision will be issued herein. REMAND At the outset, the Board notes that in the Veteran's Motion for Reconsideration, it was reported that relevant VA medical records had not been associated with the claims file prior to adjudication of the claims. While the appellant's representative submitted additional VA medical records in support of the claims on appeal, a review of the records suggest that additional treatment has been provided. On remand, outstanding VA treatment records must be obtained. The Veteran asserts that a separate award of service connection should be granted for a psychiatric condition other than the service-connected pain disorder. The claimant was provided a VA examination in March 2010 where she was diagnosed with malingering, dysthymic disorder, and personality disorder. A VA examination was also afforded in October 2012 where panic disorder without agoraphobia and mood disorder were diagnosed. The examiner determined that the Veteran had more than one psychiatric disorder, but it was not possible to differentiate what symptoms were attributable to each diagnosed psychiatric disorder due to overlap in symptoms. Subsequent VA medical records associated with the claims file following the October 2012 VA examination demonstrated diagnoses of panic disorder, adjustment disorder, and depressive disorder. The Board finds that a VA examination should be provided to determine the etiology of the disorders and to determine if the symptoms associated with such disorders are distinguishable from those of the service-connected pain disorder. The appellant also asserts that a rating in excess of 30 percent is warranted for her service-connected pain disorder. In the appellant's Motion for Reconsideration, her representative noted that the Veteran suffered from psychogenic nonepileptic stress attacks, which she contends are related to the appellant's service-connected pain disorder. In an August 2013 VA medical note, it was mentioned that the Veteran reported episodes of loss of time. The physician was suspicious that they were fugue states. A neurology record dated in June 2014 for the appellant's epilepsy noted that the Veteran experienced loss of time/consciousness at least 2 times per week which the appellant stated could last for up to two days. It was reported that the habitual attacks represented psychogenic nonepileptic events, possibly reflecting underlying somatoform, dissociative, and/or other non-physiologic process( es). In a neurological follow-up in June 2014, it was noted that psychogenic nonepileptic stress attacks were positive for memory malingering due to poor effort. On remand, a VA examination should be provided to determine the current severity of the Veteran's service-connected pain disorder and for an opinion to be provided as to whether the psychogenic nonepileptic stress attacks are a symptom of that condition. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA medical records from June 2011 to the present. 2. Thereafter, schedule the Veteran for a VA examination to determine the severity of her service-connected pain disorder and to determine the etiology of any psychiatric condition other than pain disorder. The claims file should be reviewed by the examiner and such review should be noted in the examination report. The examiner should identify all psychiatric disorders found on examination. For any psychiatric disabilities other than pain disorder, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or more) that any diagnosed disorder had its onset during military service or is otherwise related to such service. If not, the examiner should state whether any psychiatric disabilities other than pain disorder were caused or aggravated (permanently worsened) by pain disorder. Additionally, the examiner should identify symptoms associated with any diagnosed psychiatric disorder that are not also a component of the Veteran's pain disorder. With regard to the service-connected pain disorder, the examiner should identify the nature, frequency, and severity of all current manifestations of the condition. The examiner should specify whether there are physical manifestations or other symptoms not contemplated by the general rating formula for mental disorders. The examination report should include a Global Assessment of Functioning (GAF) score on Axis V and an explanation of the significance of the current levels of psychological, social, and occupational functioning that support the score. The examiner must provide a rationale for any opinion provided. If an opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiner must specifically discuss the diagnosis of psychogenic nonepileptic stress attacks, to include the date of onset of the condition, symptoms associated with the condition, and provide an opinion as to whether it is a symptom associated with the service-connected pain disorder. 3. If the benefits sought on appeal are not fully granted issue a supplemental statement of the case. Then return the case to the Board, if in order. 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 2014). ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015). Citation Nr: 1542096 Decision Date: 09/29/15 Archive Date: 10/05/15 DOCKET NO. 12-24 275 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, other than pain disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 30 percent for pain disorder. 3. Entitlement to a rating in excess of 20 percent for chronic low back pain with degenerative disc disease L5-S1. 4. Entitlement to an initial rating in excess of 10 percent for right leg radiculopathy. 5. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Stacey P. Clark, Attorney ATTORNEY FOR THE BOARD C. Jones, Associate Counsel INTRODUCTION The Veteran had active military service from April 1987 to June 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York and an April 2010 rating decision from the RO in St. Petersburg, Florida. In the March 2004 rating decision, the RO granted service connection for right leg radiculopathy and assigned a 10 percent rating, effective June 20, 2003, and increased the rating for the Veteran's lumbar spine disability to 20 percent disabling, effective June 20, 2003. The rating decision also denied entitlement to a TDIU. Thereafter, in a July 2004 rating decision, the RO assigned an effective date of May 2, 2003 for the grant of service connection for right leg radiculopathy and for assignment of the 20 percent disability for the Veteran's service-connected lumbar spine disability. Subsequently, jurisdiction was transferred to the RO in St. Petersburg, Florida. In a May 2009 decision, the Board remanded the issues of entitlement to an increased rating for a lumbar spine disorder and radiculopathy of the right leg and entitlement to a TDIU for additional development. In the April 2010 rating decision, the RO denied service connection for PTSD and entitlement to an increased rating for the appellant's service-connected pain disorder. In a January 2012 decision, the Board recharacterized the issue of entitlement service connection for PTSD as stated on the title page. Additionally, the Board remanded the issues of entitlement to service connection for a psychiatric disorder, entitlement to increased ratings for pain syndrome, a lumbar spine disability and radiculopathy of the right leg and entitlement to a TDIU for further development. The issues of entitlement to an increased rating for a lumbar spine disability and right leg radiculopathy and entitlement to a TDIU are addressed in the REMAND portion of the decision below and REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have a psychiatric disorder that is separate from her already service-connected pain disorder. 2. The Veteran's pain disorder has been manifested by symptoms to include depressed mood, anxiety, panic attacks, disturbances of motivation and difficulty establishing and maintaining effective work and social relationships; her disability picture has not been manifested by occupational and social impairment with reduced reliability and productivity or by difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, other than pain disorder, to include PTSD, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 2. The criteria for a rating in excess of 30 percent for pain disorder have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321, 4.7, 4.10, 4.130, Diagnostic Code 9412. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist Veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). VCAA requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. For increased rating claims, section 5103(a) requires the Secretary "to notify the claimant that to substantiate such a claim the claimant should provide or ask the Secretary to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment." Vazquez-Flores v. Peake, 24 Vet.App. 94, 102-03 (2010) [hereinafter Vazquez-Flores v. Peake II] (citing Vazquez-Flores v. Peake, 580 F.3d 1270, 1279-80 (Fed.Cir.2009) and Vazquez-Flores v. Peake, 22 Vet.App. 37, 43 (2008)). The Veteran received notification prior to the unfavorable agency decision in letters dated in March 2009 and June 2009. Specifically, she was apprised of information and evidence necessary to substantiate his claim. She was notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. She was also informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Service treatment records (STRs) are associated with the claims file. Pursuant to the Board's January 2012 remand directives, all outstanding VA treatment records have been obtained. Social Security Administration (SSA) records have also been associated with the claims file. The Veteran was afforded examinations in conjunction with her claims on appeal. These examinations are adequate for the purposes of evaluating the Veteran's claims on appeal, as they involved a review of the Veteran's pertinent medical history as well as a clinical evaluation of the Veteran, and provide a discussion of pertinent symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Additionally, a statement of the case was issued in June 2012. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. I. Service Connection Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131. To establish service connection the evidence must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). There are particular requirements in 38 C.F.R. § 3.304(f) for establishing PTSD that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) an in-service stressor with credible supporting evidence that the in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f); See also Cohen v. Brown, 10 Vet. App. 128 (1997). Evidence of behavior changes, such as deterioration in work performance or substance abuse, following the claimed assault is one type of relevant evidence that may be found in these sources. 38 C.F.R. § 3.304(f)(5). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Factual Background and Analysis The Veteran contends that service connection for PTSD and depression is warranted. Specifically, she contends that PTSD is due to an in-service assault and that depression is secondary to her service-connected lumbar spine disability and pain disorder. Historically, the Board notes that the Veteran filed a claim of service connection for depression April 2008. Thereafter, in an October 2008 VA examination, the she was diagnosed with chronic pain disorder, mild dysthymic disorder, mild generalized anxiety disorder and moderate personality disorder. Associated symptoms included somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety and psychoticism scales. Thereafter, in a January 2009 rating decision, the RO granted service connection for pain disorder, rated under Diagnostic Code 9412 for pain disorder and/or agoraphobia pursuant to the schedular criteria mental for disorders. Initially, Board notes that the evidence of record does not demonstrate that the Veteran has a diagnosis of PTSD. As such, service connection is not warranted for PTSD. Assuming, however, that the evidence demonstrated a diagnosis of PTSD, the Board finds that service connection is not warranted for the condition or for any other diagnosed psychiatric disorder. As previously noted, the Veteran is already service connected for a pain disorder, which is rated under the under Diagnostic Code 9412 under the General Rating Formula for Mental Disorders, and includes consideration of symptoms such as chronic sleep impairment. See 38 C.F.R. § 4.130. While the claims file is replete with complaints of and treatment for depression and a number of other psychiatric conditions, the probative medical evidence of record demonstrates that such symptomatology is a component of the Veteran's already service-connected psychiatric disability. In this regard, associated symptoms of the appellant's service-connected pain disorder include depressed mood, anxiety, panic attacks that occurred weekly or less often, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and suicidal ideation. See March 2010 and October 2012 VA Examination Reports. Therefore, to grant a separate award of service connection for depression, or for any other symptoms underlying the Veteran's service-connected psychiatric disability, would constitute impermissible pyramiding. See 38 C.F.R. § 4.14 (2015) (directing that the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided); see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Notwithstanding the rule against pyramiding, the Board recognizes that separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (2009). In determining whether a separate award of service connection is proper in this instance, the Board has relied on the findings of the October 2012 VA examiner, who found that it was not possible to differentiate what symptoms were attributable to each diagnosed psychiatric disorder due to overlap in symptoms. Notably, there is no medical evidence of record suggesting that the Veteran's depression is not a symptom of the service-connected pain disorder. Thus, a separate rating is not warranted for any additional diagnosed psychiatric disorder. In light of the foregoing, the Board finds that a preponderance of the evidence is against the claim for service connection for a psychiatric disorder, to include PTSD, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. II. Increased Rating Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as in the present case, entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the Board considers all evidence of record, the more critical evidence consists of the evidence generated during the period up to one year before the claim for increase. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The Board must consider whether the disability has undergone varying and distinct levels of severity while the claim has been pending and provide staged ratings during those periods. Fenderson v. West, 12 Vet. App. 119 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. §§ 4.7, 4.21. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Rating Criteria The Veteran's pain disorder has been assigned a 30 percent rating under Diagnostic Code 9412 for panic disorder and/or agoraphobia. Under Diagnostic Code 9412, a 30 percent rating is assigned when there is evidence 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 normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9412. A 50 percent rating is assigned where the evidence shows 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 difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned when a veteran's occupational and social impairment reflects 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned 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; and memory loss for names of close relatives, own occupation, or own name. Id. The nomenclature employed in the rating schedule is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2015). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The DSM-IV contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) because ratings of current functioning will generally reflect the need for treatment or care. While GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record. Therefore, they will not be relied upon as the sole basis for an increased disability evaluation. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Also when evaluating mental health disorders, the factors listed in the rating criteria are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether a Veteran exhibited the symptoms listed in the rating scheme. Rather, the determination should be based on all of a veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002); see also 38 C.F.R. § 4.126(a). Factual Background Private treatment records dated in December 2008 demonstrate that the appellant was hospitalized; she presented with complaints of depression and anxiety. Mental status examination indicated that she was calm and cooperative. Psychomotor skills were normal, she made good eye contact, speech was within normal limits, thought content and flow of thought was sequential, logical and goal directed, and there were no so suicidal or homicidal ideations and no evidence of psychosis. Her mood was sultry; affect was euthymic, slightly hyperthymic. Her insight and judgment were fair. She was diagnosed with mood disorder, not otherwise specified. VA medical records dated from December 2008 January 2013 also noted complaints of depression and anxiety and treatment for pain disorder, mood disorder major depressive disorder without psychotic features. GAF scores ranged from 50 to 55. Notably, in a medical December 2008 psychiatric consultation, it was noted that the appellant had fair personal hygiene and pain behaviors and made good eye contact. Her mood was depressed, affect fluctuated between irritability and dysphoria, her speech was at a normal rate and volume and her thought process was linear and goal directed to most questions except for some things she could not remember. The physician was unable to elicit any organized delusion or behaviors during the interview indicative of the appellant responding to any stimuli. She reported fleeting wishes of death that were periodically exacerbated based on her stressors, however, she insisted that she was not ruminating on any plans and that she would check into the emergency room if she felt overwhelmed with suicidal thoughts. She was alert and oriented and her concentration, insight and judgment were fair. It was noted that she had some difficulty with chronology of events, and reported lack of recollection of incidents that happened during service. It was noted that her fiancé was present during the evaluation. She was diagnosed with dysthymic disorder and depressive disorder due to chronic pain. In an April 2009 statement from the Veteran's fiancé, he reported that they had been together since July 2006 and had cohabitated for the majority of that time. He stated that he had seen the appellant deteriorate physically and emotionally since that time. He stated that when they started dating, she was vibrant and mentally superior to most. However, as their relationship progressed, he noticed a decline in her ability to remain focused on her responsibilities, both domestically and professionally. Her short term memory was faulty which required him to take responsibility of their lives, which included paying the bills and making sure the appellant takes her medication. He further reported that she talked about possible thought of suicide. The Veteran was afforded a VA examination in March 2010. Her reported symptoms included memory problems, difficulty concentrating and nightmares. She stated that she had a good relationship with her three adult children and one of her daughters lived with her. Additionally, she had a very good relationship with her mother and a distant relationship with her father. She was not in a relationship at the time of the examination. Although most of her friends lived out of the area, she stated that she talked to them on a weekly basis or sometimes every other week. She did not have any recreational activities but indicated that she had been trying to go to a club once per month for lunch. She reported that she was unemployed, due in part to her chronic depression and that she had panic attacks when driving. However, the examiner noted that there was no apparent impairment in thought process and communication and her behavior as unremarkable. On mental evaluation, the appellant was fully oriented, well-groomed and cooperative. Her mood was presented as mildly depressed and labile with somewhat constricted affect. She denied suicidal intent or planning, homicidal ideations, hallucinations and delusions. Attention, memory and judgment were within normal limits. Psychological testing results were consistent with definite malingering. The examiner noted that the response styles in the current examination were particularly pronounced with regard to reported symptoms of mood disorder and somatic symptomatology thus rendering the diagnosis conferred in an October 2008(chronic pain disorder with associated psychological factors and general medical condition, mild dysthymic disorder, mild generalized anxiety disorder and moderate personality disorder) examination questionable. It was noted that that the testing instruments used in the current examination were not available in the October 2008 examination. The examiner diagnosed malingering, dysthymic disorder and personality disorder. A GAF score of 75 was assigned which was based on the Veteran's service-connected condition and was speculative and conservative due to the results of objective testing. The examiner assigned GAF scores of 65 for dysthymic disorder and 55 for personality disorder, which were both noted as speculative. The examiner noted that pain disorder and panic disorder were not diagnosed in the current examination because the results of objective testing were consistent with the significat feigning of general psychopathology, subjective pain, somatic symptomology and functional impairment. Additionally, dysthymic disorder and personality disorder were likely caused by reported events that preceded the Veteran's military service. Additionally, symptoms of pain, if any, appeared to be much more sternly associated with the appellant's psychological factors than with her general medical conditions. The examiner determined that due to the result of objective testing, the current nature and severity of the Veteran's mental health condition was unclear; therefore the relationship between her mental health and current occupational and social functioning was also unclear. Further, the appellant's reported impairment in social and functional occupational functioning was not adequately corroborated by any collateral information available to the examiner. The appellant was afforded an additional VA examination in October 2012. During clinical evaluation, she reported that she had been involved with her ex-husband for the past three and half period. She lived with her mother and her 32 year old daughter. She attended monthly meetings with the "Lady Red Hatters Society"; however she had not attended since July. The examiner noted a diagnosis of panic disorder without agoraphobia and mood disorder. The examiner determined that it was not possible to differentiate the symptoms attributable to each diagnosis due to overlap in symptoms with one condition exacerbating the other. The examiner noted that there was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although the Veteran was generally functioning satisfactorily with normal routine behaviors, self-care and conversation. Symptoms associated with the condition included depressed mood, anxiety, panic attacks that occurred weekly or less often, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and suicidal ideation. The examiner noted that the Veteran was very talkative and had to be redirected at times to stay on topic. Psychomotor activity was elevated. She was constantly moving. She was also animated and dramatic in her speech and mannerisms. The examiner reported that she received a GAF of 43 for her depression and a 50 for her anxiety, indicative of severe symptoms or. The examiner determined that neither the panic disorder nor mood disorder rendered the appellant unable to secure or follow a substantially gainful occupation. She noted that the Veteran was able to communicate effectively and understand and carry out at least simple instructions. Her thoughts were logical and goal-directed with no evidence of formal thought disorder. Additionally, her judgment was unimpaired. Social security administration records demonstrated the award of benefits for affective/mood disorder and disorders of the back. Analysis Based on the above, the Veteran's pain disorder most nearly approximates the criteria for the current 30 percent and a higher rating is not warranted for any portion of the rating period on appeal. The claimant has exhibited symptoms of depressed mood, anxiety, panic attacks, and disturbances of motivation and mood, which are contemplated by the current 30 percent evaluation. Moreover, her pain disorder symptoms have not resulted in occupational and social impairment with reduced reliability and productivity, as is required for a 50 percent rating under Diagnostic Code 9412. In so finding, the October 2012 VA examiner determined that the Veteran was able to communicate effectively and understand and carry out at least simple instructions. Additionally, the Veteran reported that she maintained good social interaction with family members, communicated with friends, participated with a social society and was in a relationship. In finding against a 50 percent rating, the evidence fails to show that the Veteran suffers from flattened affect, circumstantial, circumlocutory, or stereotypical speech, panic attacks more than one a week, difficulty in understanding complex commands, impaired short and long term memory, impaired judgment or abstract thinking, or difficulty in establishing and maintaining effect work and social relationships. While the record demonstrates that the Veteran has reported suicidal thoughts, such symptom has not been shown to have had an impact on her overall ability to function socially or occupationally. Therefore, this symptom, standing alone, does not indicate a disability picture commensurate with the next-higher 50 percent rating. Again, the symptoms that have been demonstrated have not been shown to result in approximate occupational and social impairment with reduced reliability and productivity. The Board notes that the reported GAF scores ranged from 75 to 43. Although a GAF score of 43 is indicative of serious symptoms or serious impairment in social, occupational or school functioning, the Board notes that, while important, the GAF scores assigned in a case are not dispositive of the evaluation and must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). The Board has considered the actual symptoms and resulting impairment as set forth above, and concludes that a rating in excess of 30 percent is not warranted. Thus, the Board determines that throughout the rating period on appeal the preponderance of the evidence is against the assignment of an evaluation in excess of 30 percent for the Veteran's pain disorder. 38 C.F.R. § 4.7. The Board has also considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b) (1). However, this case does not present such an exceptional or unusual disability picture that it would be impracticable to apply the schedular standards, and referral is unnecessary. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Rather, the manifestations of the Veteran's pain disorder, including depression, anxiety and difficulty concentrating, are fully contemplated by the schedular rating criteria and this analysis. As such, referral for consideration of an extra-schedular rating is not necessary at this time. See Thun, 22 Vet. App. at 115-16. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for additional disability from a combined effect of multiple conditions. ORDER Entitlement to service connection for a psychiatric disorder, other than pain disorder, to include posttraumatic stress disorder (PTSD) is denied Entitlement to a rating in excess of 30 percent for pain disorder is denied. REMAND Most recently, the Veteran was afforded a VA examination for her lumbar spine disability in September 2012. At the time of the examination, she denied flare-ups of the low back pain since approximately 2006. However, a review of the claims file notes that during examinations in December 2003, February 2006 and June 2011, the Veteran reported flare-ups. However, the examiners who conducted the examinations did not address whether there would be any functional loss of function on flare-up. Mitchell v. Shinseki, 25 Vet. App. 32 (2011); see 38 C.F.R. § 4.40 (2015); DeLuca v. Brown, 8 Vet. App. 202, 205-6 (1995). This must be accomplished on remand. The Board notes that the issues of entitlement to an increased rating for right leg radiculopathy and entitlement to a TDIU are inextricably intertwined with the increased rating claim for the lumbar spine. Therefore, the Board must defer adjudication of the claims. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: 1. The RO should arrange for an orthopedic examination of the Veteran to determine the current severity of her service-connected lumbar spine disability. The claims folder must be reviewed by the examiner in its entirety in conjunction with the examination. Complete range of motion testing should be accomplished and the examiner should note the point at which there is pain on motion, if any. The examiner should also note any additional loss of function with repetition due to factors such as pain, weakness, fatigability, and pain on movement. The examiner must also specifically discuss whether the Veteran's flare-ups are associated with additional functional loss- if so; he or she should estimate the degrees of lost motion during such flare-ups. The examiner must also discuss flare-ups reported in the previous VA examinations (dated in December 2003, February 2006, and June 2011) and estimate the degrees of lost motion during the reported flare-ups, if possible. Any incapacitating episodes of the lumbar spine requiring physician-prescribed bed rest should be noted, along with their frequency and duration over the past 12 months. Complete neurologic findings should also be included. The severity of each neurological sign and symptom must be reported, if such exists, as mild, moderate, moderately, or severe in nature, and whether such represents symptomatology that more closely approximates incomplete or complete paralysis of the affected nerves. The examiner must also discuss the Veteran's reports of flare-ups of radicular symptoms reported in the July 2011 examination report and determine the severity of the condition during such period, if possible. The examiner is also asked to comment on the impact of the of the Veteran's disabilities, if any, on her employment and activities of daily life. The examiner is requested to provide a rationale for any opinion expressed. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 2. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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 2014). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs