Citation Nr: 1746830 Decision Date: 10/19/17 Archive Date: 10/31/17 DOCKET NO. 11-20 009 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to January 5, 2009, and to a rating in excess of 50 percent as of January 5, 2009, for service-connected schizophrenia. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Jane R. Lee, Associate Counsel INTRODUCTION The Veteran served on active duty for training from March 1985 to May 1985, and on active duty from August 1987 to June 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. Jurisdiction of this case is currently with the RO in St. Petersburg, Florida. In January 2010, the RO denied service connection for schizophrenia and for a left shoulder disorder due to lack of new and material evidence. The Veteran submitted a timely Notice of Disagreement (NOD) for both issues in February 2010. Thereafter, in June 2011, the RO granted service connection for schizophrenia and assigned a 50 percent rating, effective January 5, 2009. The Veteran appealed both the effective date and the assigned rating. In July 2015, the RO denied a TDIU, and the Veteran submitted a timely NOD in July 2015. In March 2016, the Board granted an earlier effective date of June 10, 1989, for the grant of service connection for schizophrenia; and remanded the issues of a higher rating for schizophrenia, service connection for a left shoulder disorder, and entitlement to a TDIU for further evidentiary development. The RO issued a November 2016 rating decision effectuating the Board's grant of an earlier effective date for the Veteran's schizophrenia, and assigned a 30 percent rating. It also granted service connection for a left shoulder disorder. As the claim for service connection for a left shoulder disability has been resolved by a full grant of benefits, the Board finds that this issue is no longer part of the current appeal. See 38 C.F.R. § 19.26(d) (2017). Below, the Board awards a higher rating of 70 percent for service-connected schizophrenia for the entirety of the appeal period. The issues of entitlement to an initial rating in excess of 70 percent for service-connected schizophrenia, as well as entitlement to a TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT For the entirety of the appeal period, the Veteran's service-connected schizophrenia is most appropriately characterized by lesser symptomatology so as to produce severe impairment of social and industrial adaptability; or occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSION OF LAW For the entirety of the appeal, the criteria for a rating of 70 percent for schizophrenia have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.132, Diagnostic Code (DC) 9203 (1988), 4.130, DC 9203 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Preliminary Matter In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Claim for Higher Ratings for Schizophrenia The Veteran contends that ratings in excess of 50 percent for schizophrenia are warranted from the effective date of June 10, 1989, i.e., the day after date of service separation. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's acquired psychiatric disorder has been currently evaluated at 30 percent, effective June 10, 1989; and 50 percent, effective January 5, 2009, under 38 C.F.R. §§ 4.132, DC 9205-9203 (1988), 4.130, DC 9205-9203 (2017). Where a law or regulation changes during the pendency of a claim, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03, 69 Fed. Reg. 25179 (2004). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C.A. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C.A. § 5110 (West 2002). Effective February 3, 1988, schizophrenia under DCs 9201 to 9205 was governed by a General Rating Formula for Psychotic Disorders. A 30 percent rating is warranted where there is definite impairment of social and industrial adaptability. A 50 percent rating is warranted where there is considerable impairment of social and industrial adaptability. A 70 percent rating is warranted where there is lesser symptomatology such as to produce severe impairment of social and industrial adaptability. A 100 percent rating is warranted where there are active psychotic manifestations of such extent, severity, depth, persistence, or bizarreness so as to produce total social and industrial inadaptability. Effective November 7, 1996, DCs 9201 to 9205 are governed by a General Rating Formula for Mental Disorders, which provides for the following rating criteria: A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and/or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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/or memory loss for names of close relatives, own occupation, or own name. In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. 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). Ratings are assigned according to the manifestation of particular symptoms, but the use of a term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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, 442 (2002). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). A GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) or no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. See Diagnostic and Statistical Manual for Mental Disorders, Fourth edition, p. 46 (1994). Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. at 47. Scores ranging from 41 to 50 reflect 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). Id. Scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). Id. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. In this case, a September 1989 VA examination report reflects an in-service diagnosis of schizophrenia personality disorder. The examiner noted that the Veteran was neatly groomed and quiet, rocked constantly throughout the interview, and had grossly adequate memory and no sign of a gross thought disorder. The Veteran reported hearing voices, described as whispers, sometimes every morning when it was quiet or when it was crowded beginning about a month and a half ago. He reported that he sometimes felt destructive, like "tearing everything up," about four times a week since December 1987. While he did not act on that feeling, he believed that he had gotten violent about eight times "when [he could not] hold it in." He stated that he had had trouble sleeping every night since the middle of 1988; experienced excessive crying "sometimes off and on;" did not have any suicidal ideation; and had occasional "spots" of visual hallucinations. He was assessed with schizophrenia in tenuous remission. An October 1989 VA examiner noted that the Veteran was a poor historian as he stated that he was hospitalized for two and a half months prior to separation from service, although the examiner could not find such indication in the claims file. On mental status examination, the Veteran was anxious, tense, suspicious, and extremely guarded. He had wet palms; circumstantial speech, which was almost incoherent at one time for a brief period of time; anxious and depressed mood; flat affect; and a fairly organized thought process, except for one occasion at which time it appeared loose. He admitted to feeling like crying, occasional suicidal ideation, and auditory hallucinations for several months that told him to collect weapons and to kill people prior to his in-service hospitalization. He reported that he still heard voices at times telling him to kill. The Veteran presented a symptomatology suggestive of schizotypal personality with the exception of auditory hallucinations that was not part of the picture, and diagnosed the Veteran with schizotypal personality disorder. However, the VA examiner pointed out that the auditory hallucinations was another possibility that had to be kept in mind since schizotypals as well as schizoid personalities were at high risk of maturing to schizophrenia. In December 1989, the Veteran stated that he had a "blackout episode" and became destructive and suicidal at home in November 1989. He stated that he was taken by ambulance and hospitalized for seven days. Private treatment records reflect that the Veteran was hospitalized from November 30, 1989, to December 7, 1989, due to voices telling the Veteran to hurt himself. The Veteran reported that the voices he heard were his own voice; and that they told him many different things, including to kill himself or others, or that he was bad or no good. He stated that the most recent issue was that he "could not control himself." His symptoms became grossly apparent to his mother just a few days prior to admission. Mental status examination revealed that the Veteran was quiet; alert; responsive to questions, although he did not offer much spontaneously; and oriented to time, person, and place. He denied depression, anxiety, and suicidal thought. He had good recent and past memory and responded appropriately for the most part. The Veteran was seen daily in one-on-one psychotherapy daily, where he seemed a little guarded at times and smiled out of context at other times, as if he were responding to voices. At discharge, he was diagnosed with acute psychotic episode. From February 20, 1990, to March 22, 1990, the Veteran was again hospitalized due to episodic explosive violent behavior since 1987, which he described as usually provoked by anger, frustration, and external pressure from people around him. The Veteran stopped taking his medication three weeks prior to his admission; and noted increasing irritability, restlessness, worsening auditory hallucinations, and recurrent homicidal and suicidal thoughts. He denied any significant mood disturbance, depression, significant flashbacks, and nightmares. A mental status examination revealed rocking motion involving his upper body; clear, coherent speech with normal rate, rhythm, and volume; initially withdrawn and distant mood, which later became more friendly and warm; blunted affect with periods of inappropriate smiles; clear and organized thought process; spontaneous and logical sequence of speech without loose associations; paranoid delusions directed to people in the military; and auditory hallucinations dating back as a child, which were initially imaginary voices and friendly but later progressed to command hallucinations when in service. He repeatedly denied suicidal or homicidal thoughts, and had impaired judgment. He was diagnosed with acute exacerbation of chronic paranoid schizophrenia. His GAF score at discharge was 65. Social Security Administration (SSA) records include an April 1990 New York State Department of Social Services Disability Claim Questionnaire, on which the Veteran stated that he lived alone, that his mother assisted him with grocery shopping and/or cooking, that his mother cleaned and assisted with household chores as he was unable to complete tasks once started, and that he spent his day thinking and listening to the radio. A May 1990 psychiatric review technique reflects a diagnosis of schizophrenia, paranoid and other psychotic disorders, with symptoms of delusions or hallucinations, incoherence, loosening of associations, illogical thinking, or poverty of content of speech associated with blunted affect; and emotional withdrawal and/or isolation. The examiner found that the Veteran had moderate restriction of activities of daily living; had moderate difficulties in maintaining social functioning; and often experienced deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner (in work settings or elsewhere). Private treatment records from July 1993 to August 1993 reflect the Veteran lived with his parents, mostly spent his time around the house, went to the gym to work out, walked, read, did not watch much TV, and did not socialize much. He was neatly dressed and groomed; and somewhat detached but cooperative, friendly, and oriented. He had slower speech than average and spoke softly, blunted affect, and mild motor restlessness. He thought people talked about him, and denied voices. The impression was paranoid-type schizophrenia. Private treatment records from May 1995 to August 1995 reflect evaluation while the Veteran was incarcerated. He was neatly dressed and groomed, friendly, and spontaneous with loose associations. He had organized thinking, no delusional thoughts, no thoughts of self-harm, and no psychotic signs or symptoms. The impression was paranoid-type schizophrenia. A May 2003 VA treatment record notes that the Veteran was found sobbing and kneeling in the lobby eight days prior, at which time he endorsed depressive symptoms, irritability, paranoid ideation, and homicidal ideation, as well as two additional personalities. He denied depressive symptoms, and reported that he heard voices since childhood of stronger and weaker personalities within him. He stated that he heard arguments and demands by these voices to do destructive things. He also verbalized paranoid and grandiose ideas of people trying to hurt him because of his intelligence, much of which was directed towards his wife, whom he said took his money and deprived him of food and medications because he had not been working. He continued to have chronic homicidal ideation without plans at present. A mental status examination revealed the Veteran to be very well-groomed; cooperative; alert; and oriented to time, person, place, and situation. He rocked with closed eyes with dramatic mannerisms at times. He had quiet decreased speech; euthymic mood; somewhat inappropriate affect; thought process that was circumstantial at times; auditory hallucinations; paranoid and grandiose delusional material; some positive chronic homicidal ideations; and poor judgment and insight. He was assigned a GAF score of 29. VA treatment records from August 2003 to March 2004 reflect that the Veteran continued to hear voices, which told him to hurt himself and that others were lying and eavesdropping so that they could talk about him. He was cooperative; alert; oriented to time, place, person, and situation; irritable; and short-tempered. He displayed psychomotor agitation. He had normal rate, tone, and volume of speech; slight flattening and blunting of affect; increased agitation; some decreased or fluctuating mood with feelings of apathy; fluctuating energy levels that was hyper at times; congruent affect; logical and goal-directed thought process; had fair insight and judgment; continued sleep disturbance with fitful sleep and lucid and vivid dreams; and some depression and sadness. He denied suicidal or homicidal ideations. In December 2003, he reported some "magical thinking" in that he felt he knew what others were thinking even if they denied such, and felt like he wanted to explode although he controlled this feeling. GAF scores ranged from 29 to 35. The Veteran was eventually found to be disabled by SSA since January 5, 2009, due to paranoid schizophrenia, asthma, and left shoulder pain. However, the evidence showed that the Veteran continued to work until March 1, 2012, which was thus established to be the beginning date of his disability. A March 2011 VA examination report reflects review of the Veteran's claims file. The VA examiner noted auditory hallucinations, which began at the age of five, and continued today. The Veteran reported that his wife left in 2007 due to homicidal ideation he began having about three years ago, and that he was distant from his 15-year-old daughter. He stated that he had two friends, from whom he was distant; and liked watching movies. He reported a history of suicide attempts, although he denied any current suicidal ideation, plan, or intent. He had poor psychosocial functioning with frequent paranoid auditory hallucinations and delusions, and was distant in all his relationships. He exhibited psychomotor activity, such as hand-wringing, persistent mannerisms, repetitive acts, and restlessness. He had unremarkable speech; constricted affect; anxious mood; intact attention; circumstantial thought process; unremarkable thought content; persecutory delusions; no sleep impairment; auditory hallucinations that were not persistent; no obsessive or ritualistic behavior; no panic attacks; no suicidal or homicidal thoughts; good impulse control; and normal memory. The Veteran was suspicious, and oriented to person and place. He did not understand the outcome of his behavior or understand that he had a problem. He was employed part-time as a health and fitness consultant at the YMCA. He was diagnosed with paranoid-type schizophrenia with a GAF score of 30. The VA examiner responded "No" to all levels of occupational and social impairment caused by the Veteran's mental disorder. In his June 2011 VA Form 9, the Veteran disagreed with the 50 percent rating, and contended that a higher rating was warranted due to the economic and social deficiencies he continued to suffer. He stated that he was unable to complete his educational pursuits as it was difficult to focus on the thoughts in his head for long periods of time, that he did not like people because they were always using him, that his family did not like living with him, and that he experienced paranoid thinking. VA treatment records from May 2011 to October 2011 reflect the Veteran's reports of a good mood; of not having slept in three days; that he continued to avoid seeing his other family members besides his mother, sister, and daughter; and that he continued to hear voices that became unbearable when he was overanxious and which told him that people were conspiring against him or wanted to use him. He reported hospitalizations during service and three times post-service with two suicide attempts in 2010. He lived alone in a trailer, spent his time working on Sudoku and playing chess; and liked science fiction, action movies, and Star Trek. The Veteran was appropriately groomed, cooperative but guarded, and alert. He had psychomotor agitation in the form of rocking back and forth; normal rate, tone, and volume of speech; full range of mood; somewhat flat and distrustful affect; no suicidal or homicidal ideation; a history of audio hallucinations that were non-commands and non-threatening; linear and logical thought processes; oriented to time, person, and place; and fair judgment and insight. He became tearful at times. He was diagnosed with paranoid schizophrenia/depressive disorder not otherwise specified (NOS) with a GAF score of 41. A January 2012 VA examination report reflects review of the claims file, a diagnosis of paranoid-type schizophrenia based on the DSM-IV criteria, and a GAF score of 39. The VA examiner opined that the Veteran's schizophrenia resulted in total occupational and social impairment. The Veteran reported that he was separated from his wife for many years, had a 16-year-old daughter to whom he spoke twice per week, spoke minimally to his family members, and had no friends or social contact as he found it to be overwhelming. He watched action movies, practiced martial arts alone, and spent time "sitting down and thinking." He heard voices, which became unbearable when he became overly anxious, told him that people were conspiring against him or wanted to use him, and told him when he was in danger and when to be quiet. He felt depressed and socially isolated, and denied anhedonia/anergia and suicidal ideation. He was tangential, had some difficulty formulating cohesive thoughts, responded with nonlinear responses, and had a "detached" mood. The VA examiner described the Veteran as "severely mentally ill with 100% social debilitation and markedly severe occupational functioning." The Veteran had symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; flattened affect; speech intermittently illogical, obscure, or irrelevant; impaired judgment; impaired abstract thinking; gross impairment in thought processes or communication; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; suicidal ideation; and persistent delusions or hallucinations. In a March 2012 statement, the Veteran reported that, although he was able to focus on his tasks at work while dealing with mixed feelings on some days, it got harder to deal with the members watching him and trying to talk to him on other days when he was dealing with "the noise in [his] head." VA treatment records from March 2012 to July 2012 reflect the Veteran's complaints of near-constant auditory hallucinations and a history of command suicidal hallucinations in the past. He spent his time working out and sitting at home. The psychiatrist noted that the Veteran occasionally called or texted his daughter, and that he had been isolating from his family for some time. He was well-dressed, was not sleeping well, and appeared to be actively hallucinating by constantly glancing to the right. He was cooperative but guarded; restless; pleasant and smiling; not suicidal or homicidal; alert; oriented to time, place, person, and situation; and distracted by internal stimuli. He had full range of mood; suspicious and restricted affect; linear and logical thought processes with mild loosening of associations in July2012; limited to fair insight; fair judgment; psychomotor agitation in the form of rocking back and forth; feelings of some hopelessness and helplessness; fluctuating energy levels; occasional suicidal thoughts; occasional fleeting visual hallucinations; delusions of persecution, mind-reading, and thought insertion; no insight into these symptoms; grossly intact memory; and mildly impaired concentration due to internal stimuli. Although he had normal rate, tone, and volume of speech in March 2012, he had speech that was low in volume and halting in rate in July 2012. The diagnoses were paranoid schizophrenia/depressive disorder NOS with GAF scores of 41 and 55. VA treatment records from August 2012 to November 2014 reflect the Veteran's reports of disrupted sleep, that he was fixated on and suspicious of perceived changes in the setting of the office, and that he appeared to be distracted by internal stimuli. He was semi-cooperative, restless, tearful, angry and irritable at times, isolated, restless, defensive, guarded, and tense. His mood was "fine;" he felt "detached;" and his affect was incongruent, suspicious, peculiar, restricted, and mildly blunted. He had paucity of speech with delayed answers, answered in non sequiturs, and showed some mild loosening associations. His tone of voice was a little less suspicious but still quite anxious. He denied any suicidal thoughts. He reported frequent, near-constant auditory hallucinations which appeared to be multiple voices giving commentary that were bothersome at times. He had delusions of persecution, mind-reading, and thought-insertion. In June 2014, the Veteran reported that the Army was trying to kill him with increasing proton waves to stop his claims. His attention, concentration, insight, and judgment were poor to fair. The Veteran watched TV, and played Sudoku or spelling games. The diagnoses were paranoid-type schizophrenia and depressive disorder NOS in partial remission. The Veteran's schizophrenia, paranoid-type, resulted in severe alterations in perception, specifically auditory hallucinations, paranoia, and persecutory delusional beliefs, which made it difficult for the Veteran to take in and assimilate new information, impaired his concentration, and made him unable to interact in a social, work, or leaning environment. GAF scores ranged from 50 to 60. In November 2014, he was hospitalized for six days due to anxiety and schizophrenia. At discharge, he was anxious and cooperative with restricted affected, and denied suicidal or homicidal ideation and auditory or visual hallucinations. A March 2015 VA examination report reflects diagnoses of schizophrenia and panic disorder. The VA examiner explained that the Veteran's paranoid ideation, delusions, and hallucinations were due to schizophrenia; that his panic attacks were due to panic disorder; and that rates of obsessive-compulsive disorder and panic disorder are elevated in individuals with schizophrenia compared with the general population. He opined that the Veteran's mental diagnoses resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood; with 80 percent of this impairment due to schizophrenia and approximately 20 percent due to panic disorder, which may disrupt his functioning more briefly. The Veteran reported that he lived in the same complex as his mother, and close to his sister; and liked to play Sudoku, chess, and other games by himself. He liked to exercise at home, but if he went to the gym, he liked to go at 2 a.m. in order to avoid others. The Veteran exhibited symptoms of anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and persistent delusions or hallucinations. He was responding to internal stimuli on the day of examination, presented with delusional material, reported that he was preparing for the apocalypse, stated that his mother was trying to poison him, rocked in his seat continuously, was intermittently tearful, and was not actively suicidal or homicidal. VA treatment records from June 2015 reflect GAF scores of 45-50 and the Veteran's report of constant voices and visual hallucinations at times when the voices were bad. He was diagnosed with schizophrenia, chronic paranoia with residuals neuroleptic-induced tardive dyskinesia, such as significant rocking behaviors; depressive disorder NOS; and history of dissociative identity disorder. Subsequently in June 2015, the Veteran was admitted with a diagnosis of schizophrenia with suicidal ideation and a GAF score of 20 to 25. He reported feeling suicidal, and that voices told him he was no good. He was suspicious and guarded; nervous; dysphoric; alert; and oriented to person, place, time, and situation. He had no apparent abnormality of motor behavior; blunted and intense affect; normal rate and rhythm of speech; organized, goal-directed, tangential, and concrete thought process with perseveration; suicidal ideas with hopelessness, helplessness, worthlessness, guilt, failure, pessimism, and loss of control; paranoia; and delusions of influence and persecution. A July 2015 private treatment record reflects that the Veteran was again hospitalized with complaints of episodically disabling psychosis, questionable dysphoria, and symptoms compatible with a characterological disorder, such as paranoid and schizoid traits. The Veteran was clean and well-groomed with no evidence of involuntary movements although he appeared preferentially psychomotorly retarded; detached and guarded; relatively engageable; and oriented to person, place, time, and location. He had a somewhat suspicious mood; otherwise blunted affect; scanty and tangential speech with a somewhat irregular cadence and prosody; ongoing auditory hallucinations that was seemingly ego-dystonic, condescending, and with self-destructive innuendoes; and occasional suicidal contemplation without homicidality or obsession but with discrete delusional thinking. His judgment and insight was stated to be "Relatively adequate(?)." VA treatment records from July 2015 to September 2016 reflect that the Veteran continued to rock back and forth; had less chronic paranoia with delusional thoughts about neighbors trying to disturb him or poison him; and continued to hear chronic auditory hallucination, which was good, protective, at times irritating, and mostly comforting. His depression was gradually improving and stabilizing, his sleep was broken, and his energy and concentration levels fluctuated. The diagnoses were schizophrenia, chronic paranoid with residual symptoms; depressive disorder NOS; and history of dissociative identity disorder. The GAF score was 45-50. In his July 2015 NOD regarding his claim for a TDIU, the Veteran reported that his anxiety and panic attacks made it harder to be in crowds or in groups of three or more without having an extreme increase in negative hallucination. He stated that he had been estranged from his family for over five years. In May 2016, his girlfriend submitted a lay statement in which she stated that they had been cohabitating since July 2015, during which time she observed that the Veteran avoided moderate to large crowds as they gave him anxiety, woke up several times at night and rarely slept four to five hours without waking up at night, could only drive short distances as he otherwise got "edgy like he [was] anticipating something," and was very reclusive. An August 2016 VA examination report reflects diagnoses of unspecified schizophrenia spectrum and unspecified depressive disorder, which could not be distinguished as the symptoms overlapped. Together they resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran reported that he had been dating for the past four to five months, had a close relationship with his daughter, and did not have any close friends in whom he confided. He was employed until 2009, but resigned as he felt overwhelmed. The VA examiner found symptoms of depressed mood, anxiety, and chronic sleep impairment. The Veteran rocked back and forth in his seat, his hygiene and grooming were appropriate, and there were no behavioral signs of mania. He denied current suicidal or homicidal ideation. He reported auditory and olfactory hallucinations, and endorsed the bizarre delusional belief that people could hear his thoughts. The VA examiner stated that the Veteran's total score of feigning/exaggerating symptoms was elevated above the test author's recommended cutoff score for the identification of likely feigning, but not above the new suggested cutoff score; as such his results were indeterminate. His total score for malingering also was above the recommended cutoff score for the identification of likely feigning, but not above the new suggested cutoff score; as such his results were indeterminate. A November 2016 VA examination report reflects a diagnosis of unspecified schizophrenia spectrum, which was not severe enough to interfere with occupational and social functioning or to require medication. The Veteran reported being in a significant relationship with a girlfriend for a year, and that he lived with her and her 6-year-old son. He built with Legos, drew, did martial arts, played chess, and did Sudoku. He stated that after separation, he was hospitalized for about two months in 1989 and again in 2014, March 2015, and November 2015. He worked in a warehouse in Georgetown for two or three months in the 1990s but quit because it was overwhelming, worked at a detention center for about six months and quit, was incarcerated until 1997, worked at a warehouse for programming computers from 1997 to 2000 until it shut down, worked at a Rent-A-Center for almost six months before he quit because it was overwhelming, worked in collections for two months until he quit because he did not like it, worked three to four years as a behavior modification specialist until he resigned as it was becoming overwhelming, became executive director of a non-profit organization where he wrote programs until he quit in November 2008, and worked for two years at a YMCA until 2009. The Veteran reported a history of suicide attempts, no history of violence or assaultiveness that he stayed to himself, and always hearing voices. The VA examiner found that he had coherent and logical speech, was evasive on exploration of claimed auditory hallucinations, did not appear psychotic or delusional, and was not suicidal or homicidal. However, the Veteran's SIMS total score was elevated above the recommended cutoff score for the identification of suspected malingering, and he endorsed a high frequency of symptoms that were highly atypical in patients with genuine psychiatric or cognitive disorders. In December 2016, the Veteran's girlfriend provided a lay statement in which she stated that the Veteran had been unable to work since 2010 and had become more reclusive with time. He rarely went outside because he felt "crowded" and appeared defensive, spoke to himself as if someone was present with him throughout the day, and constantly rocked in a seated position or wrung his hands together. He could not focus long enough to draft documents without feeling overwhelmed with anxiety attacks, could not handle stress, was separated from his wife and daughter since 2008, took an unusually long time to complete basic chores due to being overwhelmed, and could not be exposed to negative opinion as it caused a "downward spiral." She witnessed the Veteran "spiral down" when there was a variation to his routine. VA treatment records from March 2017 to July 2017 reflects diagnoses of schizophrenia, chronic paranoid with residual symptoms; depressive disorder NOS; and history of dissociative identity disorder. GAF scores ranged from 45 to 50. In April 2017, the Veteran was hospitalized for five days due to impairing auditory hallucinations with suicidal ideation, and feeling overwhelmed and very anxious. He stated that "[t]he voices got really loud," and appeared to be very paranoid. He was discharged with a diagnosis of paranoid schizophrenia with acute exacerbation. Subsequently, he reported auditory and olfactory hallucinations with voices that were negative at times, although recently they had been more positive. He was easily overwhelmed when he had too much going on or if there were too many people around, and described symptoms of avoidance and hypervigilance. He described his sister and girlfriend as major sources of support; and spent a lot of time with his girlfriend's son playing with Legos and building robots, and his mother who lived in the same complex. He had been with his girlfriend since March 2015; and had a younger brother with whom he was close, three more brothers with whom he was not particularly close, and an adult daughter with whom he had a very close relationship. A July 2017 VA PTSD examination report reflects that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria, but that he had a diagnosis of schizophrenia, which resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Veteran mainly stayed home because he did not like people, and could do chores around the house although it took time "due to voices." An examination revealed that he was appropriately and casually dressed; cooperative; and oriented to person, time, place, and situation. He had normal rate and rhythm of speech; mild rocking back and forth; an anxious mood; constricted range of affect; logical, coherent, and goal-directed thought processes; mild paranoia and suspiciousness; intact memory; fair insight; and fair judgment. He denied homicidal ideations and incidents of physical aggression, but reported having passive suicidal ideation and hearing voices and described delusional thinking. He exhibited symptoms of anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in adapting to stressing circumstances including work or a worklike setting, suicidal ideation, and persistent delusions or hallucinations. In his August 2017 appellate brief, the Veteran's representative lays out the history of the Veteran's schizophrenia. He also stated that the November 2016 VA examination was inadequate as the examiner determined that the Veteran was malingering and failed to provide any of the requested opinions. He contended that the Veteran should be assigned a total rating from the time of separation as he had a more than 30 year history as a permanently and totally impaired chronic schizophrenic. He noted that the Veteran had demonstrated suicidal ideation on which he tried to act several times, was in and out of hospitals, and was totally and socially impaired. The representative contended that most of the VA examinations were "suspect" as the Veteran was such a poor historian who failed to recognize that he had a problem most of the time. He stated that the Veteran could not function under the ordinary circumstances of daily life, was not compliant with his medication, had been in and out of jail, and was a risk to others as a result of his access to weapons. If a total disability rating was not assigned, he contended that a staged rating was warranted with an initial total rating due to his extended hospitalizations that began weeks following separation from service. In his August 2017 Notice of Disagreement, the Veteran contended that a 70 percent rating was warranted for his schizophrenia. He stated that he could not be around groups of people or go out without some sort of noise cancelling device, that he could only go to places that allowed him to sit with his back to a wall and with a full view of his surrounding, that he had daily anxiety attacks throughout the day and panic attacks near night, that he was told that he wailed and lashed in his sleep, and that he stayed indoors to the point where he required a prescription for vitamin D. Based on a careful review of all of the evidence, the Board finds that an initial rating of 70 percent is warranted for the entirety of the appeal period for the Veteran's schizophrenia. During the entirety of the appeals period, the Board finds that the Veteran's psychiatric symptoms, at the very least, reflect severe impairment of social and industrial adaptability, or occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran was repeatedly hospitalized for psychiatric symptoms during the appeals period, specifically in November 1989 (just months after service separation) due to voices telling him to hurt himself, February 1990 due to episodic explosive violent behavior, November 2014, June 2015, July 2015, and April 2017. The Veteran reported auditory hallucinations, which at times instructed him to kill others, told him to hurt himself, and told him that others were lying and eavesdropping, as well as occasional visual hallucinations. Additionally, he described paranoid delusions of persecution, mind-reading, and thought insertion, such as believing that he knew what others were thinking, that his wife was trying to hurt him by taking his money and depriving him of food and medication, that the Army was trying to kill him with increasing proton waves to stop his claims, that others were lying or eavesdropping so that they could talk about him, that his mother was trying to poison him, and that his neighbors were trying to disturb or poison him. In January 2014, Dr. J.R. found that the Veteran's persecutory delusional beliefs with auditory hallucinations were such that he was unable to interact in a social, work, or learning environment. The evidence also reflects that the Veteran rocked constantly throughout this period of time; and that he had circumstantial speech which became almost incoherent at times, flattened affect, distant mood, poor to fair judgment and insight, gross impairment in thought processes or communication, and difficulty in adapting to stressful circumstances including work or a worklike setting. SSA records reflect that he was found to have incoherent, loosening of associations; illogical thinking; or poverty of content of speech. The Veteran described instances of impaired impulse control with feelings of destruction and violence. Additionally, the evidence demonstrates that the Veteran was unable to establish and maintain effective relationships. He stated as early as July 1993 that he did not socialize much, mentioned at his March 2011 VA examination that he had two friends from whom he was distant, and stated in January 2012 that he had no friends or social contact as he found it to be overwhelming. He also reported that he avoided seeing his family members besides his mother, sister, and daughter with periods of time where he described his relationship with them as distant. The Veteran started living with his girlfriend in July 2015, who stated that the Veteran avoided crowds as they gave him anxiety, was very reclusive, and could not handle stress. The November 2016 VA examination report also reflects that the Veteran worked on and off until 2009, but that he quit many positions since the 1990s due to feeling overwhelmed. SSA records reflect that a May 1990 examiner found the Veteran to have moderate difficulties in maintaining social functioning; and to often experience deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner in work settings. The January 2012 VA examiner described the Veteran as "severely" mentally ill. Although she found the Veteran's schizophrenia to result in total occupational and social impairment, she then described him as having "100% social debilitation and markedly severe occupational functioning," rather than total impairment both socially and occupationally. Additionally, the March 2015 VA examiner found that the Veteran was occupationally and socially impaired with deficiencies in most areas, with 80 percent of this impairment resulting from the Veteran's service-connected schizophrenia. Additionally, the Veteran's GAF scores ranged from 20 to 65 during the appeals period. Accordingly, given the totality of the symptoms reflected in the evidence and the level of social and occupational impairment reflected in the various examinations, the Board finds that the Veteran's schizophrenia warrants at least a 70 percent rating with symptoms remaining consistent in severity for the entirety of the appeal period. The Board acknowledges the more recent August 2016 and November 2016 VA opinions and findings of feigning/exaggerating symptoms. However, the remaining evidence reflects that the Veteran has consistently reported symptoms, such as auditory hallucinations, delusions and paranoia, and suicidal ideation since the first claim filed. As discussed further below, the Board finds that these VA opinions to be insufficient and thus less probative, especially when compared to the extensive treatment records and the Veteran's consistent reports of symptoms since 1989. Therefore, based on the overall level of industrial/occupational and social impairment, the Board finds that the Veteran's schizophrenia at least approximates the criteria for a 70 percent rating for the entirety of the appeal period. ORDER For the entirety of the appeals period, entitlement to an initial rating of 70 percent for the Veteran's service-connected schizophrenia is granted, subject to the laws and regulations governing monetary benefits. REMAND As determined above, the Board has assigned an increased rating of 70 percent for the Veteran's schizophrenia based on the evidence currently of record. However, to assess whether an even higher rating is warranted, the Board finds that remand is required to obtain an updated VA examination. Pursuant to the March 2016 remand, the AOJ, in pertinent part, obtained VA examinations in August and November 2016 in order to evaluate the Veteran's service-connected schizophrenia, as well as a VA "posttraumatic stress disorder (PTSD)" examination in July 2017. However, the Board finds these VA examinations to be inadequate to evaluate whether a rating higher than 70 percent is warranted. The 2016 VA examiners noted that the testing conducted during the compensation examinations identified feigning and suspected malingering. As highlighted above however, the Board found those test scores inconsistent with the Veteran's remaining mental health records dating back to 1989. The Veteran's representative also raises issue with the adequacy of these opinions and findings. Further, the August 2016 VA examiner, who provided a November 2016 addendum opinion to comment on the severity of the Veteran's schizophrenia since 1989, stated that he "would have to resort to mere speculation to provide this opinion." The Board notes that a mere recitation by the VA examiner that he or she cannot provide a medical opinion without resorting to speculation by itself is not dispositive, where there is no clearly obvious rationale offered for why this was the case. See Jones v. Shinseki, 23 Vet. App. 382 (2010). In this case, the VA examiner's reasoning for being unable to provide an opinion without resorting to speculation is deficient. Thus, to ensure that the Veteran's schizophrenia has been adequately evaluated by a VA examiner, the Board finds that an additional examination should be afforded to him. Finally, the claim for a TDIU is inextricably intertwined with the claim for higher rating for schizophrenia hereby remanded, and the adjudication of the TDIU claim may depend on the outcome of the claim for higher ratings for schizophrenia. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Accordingly, the case is REMANDED for the following action: 1. Obtain a new VA mental health examination to ascertain the nature, extent, and severity of the Veteran's service-connected schizophrenia. The entire claims file must be provided to the examiner for review. All necessary tests and studies should be accomplished and all clinical findings reported in detail. Note: The Veteran's schizophrenia is now rated as 70 percent disabling since June 1989. After reviewing the entire claims file, specifically to include those mental health records dated from June 1989 forward, and examining the Veteran, the examiner should: Assess the severity of the Veteran's schizophrenia since June 1989 and then specifically provide an opinion as to whether the disability SINCE JUNE 1989 has ever resulted in: (a) total social and occupational impairment, or (b) psychotic manifestations of such extent, severity, depth, persistence, or bizarreness so as to produce total social and industrial inadaptability. **In providing the above-requested assessment, please provide a RETROSPECTIVE with an explanation for any conclusions reached. 2. After conducting all other development deemed necessary, readjudicate the Veteran's claims for entitlement to an initial rating higher than 70 percent for schizophrenia and for entitlement to a TDIU. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. The Veteran 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). ______________________________________________ S. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs