Citation Nr: 1824955 Decision Date: 04/25/18 Archive Date: 05/03/18 DOCKET NO. 09-38 139 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent prior to February 23, 2010, and in excess of 50 percent from February 23, 2010 to January 30, 2012, for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for a respiratory disorder, including allergies. 4. Entitlement to a total disability rating based upon individual unemployability (TDIU) prior to January 30, 2012. REPRESENTATION Appellant represented by: Georgia Department of Veterans Service WITNESS AT HEARING ON APPEAL The Veteran and his friend ATTORNEY FOR THE BOARD Donna D. Ebaugh, Counsel INTRODUCTION The Veteran served on active duty from March 1968 to October 1969. This matter comes before the Board of Veterans' Appeal (Board) on appeal from a November 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In May 2013, the Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference; a transcript of the hearing is associated with the file. In July 2013, the Board remanded the claims for additional development, including the claim of entitlement to a TDIU due to the Veteran's service-connected PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Following such development, in a June 2014 decision, the Board denied the Veteran's claim for a higher initial rating for PTSD and remanded the remaining issues on appeal. Thereafter, the Veteran appealed the Board's June 2014 decision regarding the PTSD rating, to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a Joint Motion for Remand (JMR), the Secretary and the Veteran's attorney limited the appeal to the issues of an initial rating in excess of 30 percent prior to February 23, 2010, and a rating in excess of 50 percent thereafter, for the Veteran's service-connected PTSD. In March 2015, the Court remanded these issues to the Board pursuant to the terms of the JMR. In September 2015, the Board remanded the increased ratings claims for the Veteran's service-connected PTSD, for development in accordance with the JMR. In February 2017, the all of the claims were returned to the Board. At that time, the Board denied a claim for a higher disability rating for hearing loss and remanded the remaining claims on appeal. While on remand, the Agency of Original Jurisdiction (AOJ) granted the claims for service connection for neurological disorders of the bilateral upper extremities, thus those claims are no longer on appeal. The AOJ also increased the Veteran's disability rating for PTSD to 100 percent from January 30, 2012. Thus, the claim for an increased rating for the period from January 30, 2012 has been satisfied in full. However, inasmuch as higher ratings are available for the periods prior to January 30, 2012, and the Veteran is presumed to seek the maximum available benefit for a disability, the claims for higher ratings for the earlier periods remain viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Further, as the Veteran claimed entitlement to TDIU specifically due to PTSD, the AOJ found the claim for TDIU from January 30, 2012 to be moot and recharacterized the claim as stated on the title page above. The Veteran does not contend otherwise; thus, the Board has continued this characterization of the appeal for TDIU. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for a respiratory disorder, and obstructive sleep apnea and entitlement to a TDIU prior to January 30, 2012, 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 period from the date of service connection prior to January 30, 2012, the Veteran's service-connected PTSD was manifested by occupational and social impairment with reduced reliability and productivity due to occasionally circumstantial thought process, and impaired attention, concentration, insight, and judgment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work relationships without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period prior to February 23, 2010, the criteria for an initial disability rating of 50 percent, but no higher, for service-connected PTSD are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.7, 4.130, Diagnostic Code 9411 (2017). 2. For the entire period prior to January 30, 2012, the criteria for a disability rating higher than 50 percent for PTSD are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Development is discussed below. 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. Historically, service connection for PTSD was granted in the November 2007 rating decision. The AOJ assigned an initial 10 percent disability rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, effective February 28, 2007. The present appeal arises from the Veteran's disagreement with the initial disability rating assigned. In July 2009, the AOJ increased the Veteran's initial disability rating to 30 percent, effective February 28, 2007. In November 2013, the AOJ again increased the Veteran's disability rating to 50 percent, effective February 23, 2010, the date of a VA treatment record which it found showed increased PTSD symptomatology. In June 2014, the Board denied increased ratings, the Veteran appealed to the Court, and remanded the case to the Board for better explanation of the reasons and bases of the decision. The Board remanded the appeal. While on remand, the AOJ granted an increased rating to 100 percent from January 30, 2012 but continued the 30 and 50 percent ratings for the earlier periods. PTSD is evaluated under a general rating formula for mental disorders. See 38 C.F.R. § 4.130, DC 9411. A 30 percent rating is warranted where there is an 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, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted where there is an occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereo-typed 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. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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 the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The Global Assessment of Functioning is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A score of 61 to 70 is defined as indicating some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning but generally functioning pretty well, has some meaningful interpersonal relationships. See Carpenter v. Brown, 8 Vet. App. 240, 242- 244 (1995). The Board notes that the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Board also notes that the DSM-IV has been updated and the DSM-V no longer uses the GAF score. The Board has reviewed all of the lay and medical evidence of record and resolving all doubt in favor of the Veteran, finds that the Veteran's PTSD symptoms are of the severity, frequency, and duration to support an initial 50 percent disability for the period prior to February 23, 2010. In this regard, the Board notes that evidence indicates that the Veteran experienced pertinent symptoms prior to February 23, 2010, that were of substantially the same severity, frequency and duration as those experienced during the period in which a 50 percent disability rating has already been granted, between February 23, 2010 and January 30, 2012. Further, for the reasons explained below, the Board finds that a rating in excess of 50 percent is not warranted at any point prior to January 30, 2012. The Board acknowledges that some of the Veteran's symptoms ebbed and flowed throughout the entire period prior to January 30, 2012; however, resolving doubt in favor of the Veteran, the Board finds that the Veteran experienced difficulty establishing and maintaining effective work and social relationships as well as disturbances in motivation and mood, difficulty understanding complex commands, and impaired judgment prior to February 23, 2010. With respect to the difficulty maintaining effective work relationships, lay and medical evidence consistently indicates that the Veteran struggled to function at his job and then was let go in August 2007, due to his PTSD symptoms. See August 2007 VA examination report. Additionally, a November 2009 VA treatment record indicated that the Veteran reported numbness and staring into space when he should have been working. Regarding disturbances of motivation and mood, the Board notes that VA treatment records dated from June 2007 indicate that the Veteran was constantly on guard, watchful or easily startled. See June 2007 PTSD screen. Additionally, during the August 2007 VA examination, the Veteran reported difficulty sleeping as well as symptoms of anger, resentment, and depression, each occurring once per week and lasting three to five hours. The Veteran also reported that his anger had caused significant problems at work. He reported that there had been some major social functional change since he developed his psychiatric disorder, specifically that he no longer went out socially. On mental status examination, the August 2007 VA examiner noted that the Veteran's affect and mood were abnormal with depressed mood occurring as often as once per week and lasting for three days. The Veteran consistently reported to VA providers that he felt depressive symptoms more than half of the time, anhedonia with the exception of his granddaughter, and a feeling of dread since 1989. See November 2009 VA treatment record. He also reported experiencing intrusive, distressing thoughts regularly during a January 2010 VA treatment consultation. The Board finds that the described depressive symptoms are akin to the "disturbances of motivation and mood" criterion contemplated by the 50 percent disability rating criteria. Additionally, the August 2007-contract VA examiner indicated that the Veteran had difficulty understanding complex commands during the period prior to February 23, 2010. The Board acknowledges that the August 2007 VA-contract examiner offered an inconsistent report regarding whether the Veteran had difficulty understanding complex commands. In this regard, the examiner initially stated that the Veteran had difficulty understanding complex commands but later reported that the Veteran did not have difficulty understanding commands. Reviewing the context of the initial finding that the Veteran had difficulty understanding complex commands, the Board notes that an explanation immediately followed the statement, indicating that the Veteran had difficulty performing serial sevens. The Board notes that "difficulty understanding complex commands" is listed in the regulation as being supportive of a 50 percent disability rating, which the Board is granting herein. Thus, the Board resolves doubt and finds that any difficulty performing serial sevens is of the frequency, severity, and duration contemplated by the 50 percent disability rating. Regarding impaired judgment, the Veteran's insight and judgment were found be fair in November 2009 and January 2010. See VA treatment records. Impaired judgment is contemplated by the 50 percent disability rating criteria. The Board also finds persuasive a November 2009 VA treatment record which noted that the Veteran had "marked" PTSD. Additionally, in November 2009, the Veteran reported that he had experienced a passive suicidal ideation more than one year prior to the November 2009. See November 2009 VA treatment record. The Veteran also consistently reported difficulty sleeping. See e.g. VA treatment records dated in November 2009, May 2010. Resolving doubt in favor of the Veteran, for the period prior to February 23, 2010, the Board finds that the Veteran's reported symptoms are of the frequency, severity, and duration of those included in the criteria for a 50 percent disability rating. Having found that the Veteran's PTSD symptoms support a 50 percent disability rating prior to February 23, 2010, the Board has also considered whether the symptoms warrant a 70 percent disability rating, or higher, at any point prior to January 30, 2012. The Board finds that the Veteran's symptoms did not reach the level of severity, frequency, and duration to support a rating in excess of 50 percent at any point prior to January 30, 2012. Regarding the Veteran's disturbances of motivation and mood, the Board finds that these disturbances did not rise to the level of severity contemplated by the 70 percent disability rating. In this regard, the 70 percent disability rating criteria contemplates near-continuous panic or depression, which is not shown prior to January 30, 2012. To the contrary, in November 2009, the Veteran reported feeling depressed more than half the time, which is not of the frequency or severity contemplated by "near-continuous" feelings of depression. Additionally, in June 2010, the Veteran reported improvement in his mood and that he was feeling calmer and less depressed. He reported that his nightmares had been less frequent and bothersome. His affect was noted to be pleasant, calm with broad range. In December 2010, the Veteran once again reported feeling better and explained that he felt calmer and less depressed, although, he reported that he continued to experience occasional flashbacks and intrusive recollections of combat trauma frequently triggered by external cues and episodes of anger. He reported that he still had occasional episodes of anger and lability of mood but he denied any recent episodes of angry outbursts, physical altercations or other behavioral dyscontrol. The December 2010 VA clinician noted that the Veteran continued to endorse episodes of hypervigilance with perimeter checking behavior. The Veteran reported that his sleep remained stable although he continued to experience intermittent nightmares. Additionally, in October 2011, the Veteran reported some subjective improvement in mood although he still experienced difficulty getting motivated to do things. He reported that he still had episodes of anxiety and brief periods of depression but denied any recent episodes of very severe or prolonged depression. The Board finds that the Veteran's description of anxiety, depression, and difficulty feeling motivated are of the severity, frequency and duration contemplated by the 50 percent disability rating, but no higher. In this regard, the evidence does not indicate that the Veteran's hypervigilance or depression rose to the level of near-continuous depression or panic as contemplated by the 70 percent disability rating criteria, prior to January 30, 2012. The Veteran's insight and judgment varied between good and fair throughout the remainder of the period prior to January 30, 2012 but did not increase to the level of severity of impaired impulse control or grossly inappropriate behavior, as contemplated by the 70 percent and 100 percent disability ratings respectively. In this regard, VA treatment records dated in November 2009, January 2010, February 2010, May 2010, June 2010 all noted fair insight and judgement whereas subsequent VA treatment records dated in August 2010, December 2010, April 2011, May 2011, July 2011, August 2011, October 2011, and November 2011 noted that insight and judgment were good. The Board also notes that although the Veteran was found to have some impairment of thought process, the impairment is contemplated by the 50 percent disability rating criteria. The Veteran's thought process was noted to have some circumstantiality but was generally organized. See VA treatment records dated in June 2010, August 2010, December 2010, April 2011, May 2011, July 2011, August 2011, and October 2011. In November 2011, the Veteran's thought process actually appeared to have improved as the VA clinician found the Veteran to have logical thought process that was linear with tight associations. The Board finds the Veteran's impairment in thought process is adequately compensated by the 50 percent disability rating. The general rating formula suggests a 50 percent disability rating for impaired abstract thinking. There was no indication of impairment of thought process or judgment that would be indicative of gross impairment in thought processes or communication (100 percent disability rating). Similarly, VA clinicians consistently noted that the Veteran had some impairment in attention and concentration during the entire period prior to January 30, 2012. See VA treatment records dated in June 2010, August 2010, April 2011, May 2011, July 2011, August 2011, October 2011, and November 2011. However, there is no indication that the Veteran's impairment rose to the level of gross impairment in thought process or communication. Additionally, VA clinicians consistently found the Veteran to be alert and oriented, with reasonable appearance and cooperative behavior, normal speech, appropriate mood and affect that was congruent with the mood. See e.g. August 2007 VA examination report, VA treatment records dated in November 2009, January 2010, February 2010, May 2010, June 2010, August 2010, December 2010, April 2011, May 2011, July 2011, August 2011, and October 2011. The evidence does not indicate that the Veteran had symptoms such as speech that was intermittently illogical, obscure, or irrelevant. VA clinicians also consistently found that the Veteran did not have any suicidal or homicidal ideation or any aggressive thoughts. See e.g. August 2007 VA examination report, VA treatment records dated in November 2009, January 2010, February 2010, May 2010, June 2010, August 2010, December 2010, April 2011, May 2011, July 2011, August 2011, and October 2011. The Board acknowledges that in November 2009, the Veteran indicated that he had experienced passive suicidal ideation more than one year prior to the evaluation. See November 2009 VA treatment record. However, there is no indication that the passive suicidal ideation interfered with the Veteran's social and/or occupational functioning. Additionally, the remaining records do not indicate any reports of suicidal ideation. To the contrary, a March 2010 VA treatment record noted that although the Veteran described lacking motivation, energy, feeling depressed, and said "[l]ife is pretty much over," the Veteran was quick to follow that he did not mean this in a suicidal manner. The Board finds that any suicidal ideations the Veteran may have had were not of the frequency, severity, or duration to support a 70 percent disability rating. The Board acknowledges that the Veteran experienced a symptom similar to an obsessional ritual when he reported always being on guard, sitting with his back to the door, and perimeter checking behavior (see e.g. January 2010, December 2010 VA treatment records); however, there is no indication that checking the doors interfered with his routine activities as suggested by the 70 percent disability rating criterion. The Board finds the Veteran's being on guard, sitting with his back to the door, and checking of locks and doors to be of the frequency, severity, and duration of the hypervigilance symptom listed under the 30 percent disability rating. There is no indication that feeling a need to sit in a certain position, or checking locks and doors had any effect on his occupational and social functioning. Thus, the Board finds that the symptom does not rise to the level of severity, frequency, or duration to support a disability rating in excess of 50 percent. To the extent that the Veteran's feelings of always being on guard affected his occupational and social functioning, the Board finds that these feelings are contemplated by the 50 percent disability rating criteria as the criteria includes mood disturbances. The evidence does not indicate more severe disturbances of mood, such as near-continuous panic. The letter from the Veteran's VA treatment provider, Dr. D.B., also supports a 50 percent disability rating, but no higher. See July 2016 letter. In this regard, Dr. D.B. reported that he had treated the Veteran since 2010 and noted observations that during such time, the Veteran experienced persistent insomnia with nightmares, flashbacks, intrusive recollections, hypervigilance, irritability, avoidant and self-isolative behaviors, periods of emotional numbing with feelings of detachment. The Board finds that Dr. D.B.'s description of the Veteran's symptoms is consistent with the documented reports in the VA treatment records, sworn testimony, and VA examination reports. For the reasons stated above, the Board finds these symptoms to be of the severity, frequency and duration contemplated by the 50 percent disability rating but no higher. The Board observes that the Veteran was provided with VA psychiatric examination in September 2013. Although that examination took place during a period for which the assigned rating is not on appeal, the Board notes that portions of the examination report are relevant to the earlier appeal period. The September 2013 VA examination report indicates that during the entire period between the August 2007 VA examination and the September 2013 VA examination, the Veteran experienced flashbacks, intrusive recollections and nightmares of combat trauma events. The examiner also noted that Veteran had hyperarousal symptoms such as anxiety, irritability with history of angry outbursts, and hypervigilance with frequent perimeter checking behavior. The Veteran also reported avoidance of triggers to traumatic memories, self-isolative behavior, and periods of emotional detachment from others. The Veteran also reported significant problems with attention and concentration. He also reported having periods of anxiety lasting several days as well as frequent lability of mood with unexplained anger that escalated rapidly sometime led to angry outbursts. The Board finds that the symptoms described as occurring since the August 2007 VA examination are of the frequency, severity, and duration to support a 50 percent disability rating, but no higher. In this regard, the reported symptoms are akin to disturbances of motivation and mood listed under the 50 percent disability rating criteria. As explained above, the evidence does not indicate more severe disturbances of mood, such as near-continuous depression or panic. For all of these reasons, the Board finds that the next-higher 70 percent disability rating is not warranted at any time prior to January 30, 2012. As the 70 percent disability rating criteria are not met during this period, it naturally follows that the 100 percent disability rating criteria are not met. The Veteran consistently denied symptoms of hallucinations or delusions. See e.g. VA examination report dated in August 2007 and VA treatment records dated in November 2009, February 2010. There is no indication of any gross impairment in thought processes or communication; 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, or for the Veteran's own occupation or name. See e.g. September 2013 VA examination. The weight of the evidence is against a conclusion that the Veteran's PTSD results in more than "occupational and social impairment with reduced reliability and productivity" so as to warrant a rating in excess of 50 percent at any point prior to January 30, 2012. In reaching this conclusion, the Board has considered the Veteran's sworn testimony that he takes sleeping pills; that when he wakes in the night he is hypervigilant; and that when he is in a crowd, he gets extremely nervous and cannot function. The Board has also considered the Veteran's reports of emotional numbness and that his interactions with others are very hard because people constantly ask him why he is angry. The Board also considered the Veteran's report that he had been told more than once that his facial expressions look scary. The Board has also considered the Veteran's friend, M.M.'s, sworn testimony regarding his observations of the Veteran's behavior. M.M. is an experienced Vet Center counselor and reported that at the time of the May 2013 hearing, he had known the Veteran for 35 years. He reported that the Veteran lacked concentration, had a lot of difficulty following a conversation, and rambled a lot. M.M. noted that sometimes he talked to the Veteran about something and 10 minutes later brought the subject up again and could tell from the Veteran's response that he did not remember talking about it a few minutes earlier. M.M. also observed that the Veteran's writing had deteriorated since letters that he wrote 20 years earlier. M.M. reported that the Veteran's writing at the time of the May 2013 hearing was not much better than a sixth grader in that the Veteran misspelled the simplest words and wrote in incomplete sentences. M.M. reported that it was difficult to have a conversation with the Veteran and that the Veteran was argumentative about the simplest subjects. M.M. also reported that the Veteran was hard to get along with and was not fun to be around. Considering the Veteran's and his friend's sworn testimony along with the medical evidence of record, the Board finds that the 50 percent rating contemplates the Veteran's reported symptoms during the entire period prior to January 30, 2012. In short, while the Veteran's PTSD clearly limited the ability of the Veteran to function socially and occupationally, the evidence is against finding deficiencies in most of the areas needed for a 70 percent rating or total occupational and social impairment as needed for the 100 percent disability rating. In making this determination, the Board also notes that VA treatment records consistently assigned GAF scores of 55 during this time period, which denotes 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) and is consistent with the 50 percent rating assigned for the time period in question. Further the August 2007 VA examiner noted a GAF score of 65. Although the updated, DSM-V no longer uses the GAF score, the Board notes that for the period prior to January 30, 2012, GAF scores were used to understand the severity of a patient's psychiatric disability. In evaluating the Veteran's claim, the Board is aware that the symptoms listed under the general rating formula are examples of the type and degree of symptoms for that rating, and that the Veteran need not demonstrate those exact symptoms to warrant a higher rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the Board finds that the record does not show the Veteran manifested symptoms that more nearly approximate the criteria for a rating in excess of 50 percent during the entire period prior to January 30, 2012. The Board has considered carefully the Veteran's contentions, and notes that lay testimony is competent to describe observable symptoms. The history and symptom reports have been considered, including as presented in the clinical evidence discussed above and at the May 2013 hearing before the undersigned, and in fact, support the increased rating granted herein for the period prior to February 23, 2010, but do not support a rating in excess of the disability rating to which the Veteran has been found to be entitled. Moreover, the competent psychiatric evidence offering detailed specific findings is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the lay testimony with regard to the matters the Veteran is competent to address, the Board relies upon the competent clinical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected disability at issue. In summary, and for the reasons and bases set forth above, the Board resolves doubt and finds the evidence supports an initial rating of 50 percent, but no higher, at any time during the entire period prior to January 30, 2012. The benefit of the doubt has been applied where necessary but as the preponderance of the evidence is against the grant of a rating in excess of 50 percent at any time prior to January 30, 2012, that doctrine is not for application with respect to a rating in excess of 50 percent. See Gilbert, supra. ORDER An initial rating of 50 percent, but no higher, for PTSD prior to February 23, 2010, is granted subject to the law and regulations governing the award of monetary benefits. A rating in excess of 50 percent for PTSD prior to January 30, 2012, is denied. REMAND Regarding the remaining issues on appeal, review of the file reveals that further development is necessary. With respect to the claim for service connection for a respiratory disorder, the Board observes that the October 2017 VA examination report is inadequate and for the reasons explained below, an addendum opinion is required. See Stegall v. West, 11 Vet. App. 268 (1998) (remand by the Board confers on an appellant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms). In this regard, the October 2017 VA examiner diagnosed sinusitis and rhinitis and indicated that there was clear and unmistakable evidence that the disorder(s) preexisted service and were not aggravated during service. However, the examiner did not identify the clear and unmistakable evidence, or indicate whether one or both of the diagnosed disorders preexisted service. Then, the examiner indicated that the Veteran's current respiratory disorders are not related to the respiratory symptoms in service. Such conclusion seems contradictory to the finding that one or both of the disorders preexisted service and continued through service but was not aggravated by the same. Even if the Board were to place no probative value on the examiner's finding that either disorder preexisted service, an addendum opinion would still be required regarding the relationship between the current disorders and service. Specifically, the October 2017 VA examiner opined that it was less likely than not that the Veteran's diagnoses of sinusitis and rhinitis were related to service because the Veteran's condition in service was acute and there was no chronicity of care after service. The examiner did not discuss the Veteran's report that since he returned from Vietnam, he experienced flu like symptoms, constant drainage, and sinus infections. With respect to the claims for a TDIU prior to August 2012 and service connection for sleep apnea (OSA), the Board observes that the outcome of these claims may be dependent on the outcome of the respiratory disorder claim presently at issue. See Parker v. Brown, 7 Vet. App. 116 (1994) and Harris v. Derwinski, 1 Vet. App. 180, 183 (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). In this regard, as the October 2013 VA examiner noted that the Veteran's allergic rhinitis was one of his risk factors for obstructive sleep apnea. Thus, if it is found that the Veteran's rhinitis is service-connected, he may be entitled to service connection for sleep apnea on a secondary basis. As such, the Board finds that the claim for service connection for OSA is inextricably intertwined with the claim for allergic rhinitis. Additionally, if either of these disorders is granted service connection for the period prior to August 2012, the result may impact whether a TDIU is warranted for that period. As such, the Board will not adjudicate the claims for TDIU or service connection of OSA at this time. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Seek an addendum opinion regarding whether the Veteran's current respiratory disabilities are related to service. The electronic claims files must be made available to the examiner for review. The Board leaves it to the discretion of the clinician asked to author the opinion as to whether the Veteran should be reexamined. The clinician is asked to address the following: (a) Identify any clear and unmistakable (i.e., undebatable) evidence that the Veteran's allergic rhinitis or sinusitis (or hay fever) existed prior to any period of active service. The examiner is reminded that ordinarily, self-diagnosis of a preexisting disability is not accepted as "clear and unmistakable" evidence. If the examiner believes that allergic rhinitis (or hay fever) is a disability that can be self-diagnosed, please explain. (b) If there is clear and unmistakable evidence of preexisting disability, please state if there was a permanent increase in the severity of the underlying pathology associated with the allergic rhinitis or sinusitis during service? (c) If the answer to the foregoing is yes, is there clear and unmistakable evidence (undebatable) that the increase in severity was due to the natural progress of the disease? (d) For allergic rhinitis and sinusitis, if the answer to either a, b, or c is no, is it at least as likely as not (i.e., probability of 50 percent) that the Veteran's allergic rhinitis or sinusitis had its onset during any period of service or is otherwise related to his active duty service, to include his reported exposure to monsoon conditions, sand, and bush, while serving in Vietnam? In answering this question, the examiner must consider the Veteran's lay statement that he has regularly experienced flu-like symptoms, constant drainage, and sinus infections since his return from Vietnam. The examiner is also advised that the lack of objective evidence showing treatment or complaints during service does not, in and of itself, render the Veteran's report of such not credible. Instead, the Veteran is competent to report the events that occurred during service, as well as the nature and onset of his symptoms, and his report of such is considered competent and credible unless otherwise noted. Rationale must be provided for each opinion offered. If any question cannot be answered on a medical or scientific basis without invoking processes relating to guesswork or judgment based upon mere speculation, the examiner must clearly specify in the examination report why this is so. 2. Thereafter, conduct any additional development as necessary, including obtaining a VA opinion regarding whether the Veteran's OSA is caused or aggravated by the allergic rhinitis or sinusitis if service connection is granted for the Veteran's respiratory disorder(s). Then, readjudicate the claims, including the claims for TDIU and service connection for OSA. If any benefit sought on appeal remains denied, provide the Veteran and his attorney a supplemental statement of the case and an appropriate period of time to respond. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs