Citation Nr: 0004189 Decision Date: 02/16/00 Archive Date: 02/23/00 DOCKET NO. 94-10 303 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a back disorder. 2. Entitlement to an increased rating for organic brain syndrome with skull fracture, temporal headaches and gait impairment, currently rated as 30 percent disabling. 3. Entitlement to a total disability rating, for compensation purposes, based on individual unemployability. REPRESENTATION Appellant represented by: American Red Cross WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran's active military service extended from March 1963 to February 1967 and from February 1968 to September 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 1993 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The case was previously before the Board in March 1996, when the Board denied service connection for seizures and an increased rating for left temporal bone fracture with left facial nerve paralysis. The remaining issues were remanded for medical records, examination of the veteran and rating action. The requested development has been completed. By a February 1998 rating decision, the RO increased the rating for the organic brain syndrome from 10 to 30 percent. That is not the highest rating assignable so issue remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). In December 1998, the Board again Remanded the case. The requested development was completed on the organic brain syndrome rating issue. The Board now proceeds with its review of the appeal on that issue. The development on the back issue was not completed. The Board noted that the service-connected gait impairment could be rated separately and the 1999 VA examination raised questions as to the gait impairment. Consequently, the issues of entitlement to service connection for a back disorder, entitlement to a separate rating for gait disturbance, and entitlement to a total disability rating, for compensation purposes, based on individual unemployability will be the subject of a remand at the end of this decision. In the February 1998 rating decision, at 3, the RO explained that an extraschedular rating was not warranted. 38 C.F.R. § 3.321(b)(1) (1999) provides that to accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Under Secretary for Benefits or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. The governing criteria for such an award is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked inference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The United States Court of Veterans Appeals (Court) has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. VAOPGCPREC. 6-96 (1996). FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal for an increased rating for organic brain syndrome with skull fracture, and temporal headaches. 2. The veteran does not have a skull loss. 3. The organic brain syndrome with headaches does not result in more than definite impairment. 4. The veteran does not have flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks; difficulty in understanding complex commands; more than mild impairment of memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships due to his service-connected organic brain syndrome. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for organic brain syndrome with skull fracture, and temporal headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including § 4.7 and Code 9304 (1996, 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION This claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the veteran's assertion that his service-connected disability has worsened raises a plausible claim. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). All relevant facts have been properly developed. VA has completed its duty to assist the veteran in the development of this claim. See 38 U.S.C.A. § 5107(a). The veteran has not reported that any other pertinent evidence might be available. See Epps. Service-connected disabilities are rated in accordance with a schedule of ratings which are based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). The service-connected head injury residuals are characterized as "Organic brain syndrome with skull fracture, headaches and gait impairment." Personality Disorder There are diagnoses of a personality disorder and evidence that it impairs the veteran's functioning. Personality disorders are characterized by developmental defects or pathological trends in the personality structure manifested by a lifelong pattern of action or behavior. Personality disorders as such are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c) (1999). Personality disorders are not diseases or injuries in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. § 4.9 (1999). However, service connection may be granted for psychiatric disabilities acquired in addition to personality disorders. 38 C.F.R. § 4.127 (1999). Which is the case here, with service connection being granted for the organic brain syndrome. Further, personality changes may be part of a service-connected organic mental disorder. 38 C.F.R. Part 4, Code 9327 (1999). In this case, there is no diagnosis of a current disability in which a personality disorder is part of the service-connected organic brain syndrome. Also, there has not been any evidence from a competent source which connects the personality disorder to the service-connected organic brain syndrome. In January 1998, a VA psychologist, Dr. Roper, indicated a possibility that the head injury resulted in a personality change, but such a mere possibility is not evidence of a connection. See Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Pursuant to the Board's December 1998 Remand, Dr. Roper clarified his opinion and stated that the veteran's personality disorder is not likely to be the direct and proximate result of the service-connected skull fracture. Dr. Cummings noted that there was considerable evidence that the personality disorder existed prior to service. Dr. Cummings further expressed the opinion that there was no indication that the veteran's personality disorder was related to the head injury. The doctor restated that the personality disorder was not secondary to the organic brain syndrome. As there is no medical evidence linking the personality disorder to the service-connected organic brain syndrome and two doctors have expressed opinions to the effect that the personality disorder is not part of the organic brain syndrome, the preponderance of evidence on this point establishes that the disability associated with the personality disorder cannot be rated as part of the service- connected organic brain syndrome. 38 C.F.R. § 4.14 (1999). Skull There is no evidence of loss of part of the skull, which would be separately ratable. 38 C.F.R. Part 4, Code 5296 (1999). Headaches The RO has rated the disability under diagnostic code 9304 "Dementia due to head trauma." The rating under this criteria includes purely subjective complaints such as headaches, dizziness, insomnia, etc. See 38 C.F.R. § 4.124a, Code 8045 (1999). Consequently, a separate rating is not assignable for the veteran's headache complaints. On the February 1993 VA examination, the veteran denied headaches. A May 1993 VA clinical note shows that the veteran reported headaches were becoming more severe and of longer duration. In August 1993, the veteran testified that he had headaches practically every day. A clinical note latter in August 1993, shows that medication provided good relief. Weighing the evidence, the Board finds the veteran's clinical records for treatment purposes are more persuasive than his sworn testimony for claims purposes. The preponderance of evidence on this point establishes that the veteran does not have headaches which would warrant a separate additional, compensable, rating. Organic Brain Syndrome Rating Criteria Prior to November 7, 1996, an organic mental disorder was evaluated as 100 percent disabling where the impairment of intellectual functions, orientation, memory and judgment and lability and shallowness of affect were of such extent, severity, depth and persistence as to produce total social and industrial inadaptability. With lesser symptomatology such as to produce severe impairment of social and industrial adaptability, the disability was rated at 70 percent. Considerable impairment of social and industrial adaptability was rated as 50 percent disabling. Definite impairment of social and industrial adaptability was rated as 30 percent disabling. Mild impairment of social and industrial adaptability was rated as 10 percent disabling. A noncompensable rating was assigned if there was no impairment of social and industrial adaptability. 38 C.F.R. Part 4, Codes 9300-9325 (1996). (effective prior to November 7, 1996). In Hood v. Brown, 4 Vet. App. 301 (1993), the United States Court of Veterans Appeals stated that the term "definite" as used for the 30 percent rating in 38 C.F.R. § 4.132 was "qualitative" in character, where as the other terms were "quantitative" in character, and invited the Board to "construe" the term "definite" in a manner that would quantify the degree of impairment for the purposes of meeting the statutory requirement that the Board articulate "reasons and bases" for it decision. 38 U.S.C.A. § 7104(d)(1) (West 1991 & Supp. 1999). In a precedent opinion, dated November 9, 1993, the General Counsel of VA concluded that the term "definite" is to be construed as "distinct, unambiguous, and moderately large in degree." It represents a degree of social and industrial inadaptability that is "more than moderate but less than rather large." VAOPGCPREC. 9-93 (Nov. 9, 1993). The Board is bound by this interpretation of the term "definite." 38 U.S.C. § 7104(c) (West 1991 & Supp. 1999) . Effective on and after November 7, 1996, the General Rating Formula for Mental Disorders, including dementia and other organic mental disorders, is: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name..................................... ......100 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 worklike setting); inability to establish and maintain effective relationships............................ ....................................70 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships............................ ....................50 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events)..................30 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 continuous medication............................... ..................10 A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication............................... ....................0 61 Fed. Reg. 52701, 52702 (1996). 38 C.F.R. §4.130 (1999). Where the law changes after a claim has been filed or reopened but before the administrative or judicial process has been concluded, the version most favorable will apply unless Congress provided otherwise or permitted the Secretary to provide otherwise and the Secretary did so. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). Background In considering the severity of a disability, the Board has reviewed the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2 (1999). In June 1972, a service department physical evaluation board diagnosed an organic brain syndrome secondary to a basilar skull fracture with slight social and industrial impairment. The veteran remained in active service until September 1976. On the November 1976 VA examination, the physician concluded with a diagnosis of organic brain syndrome, no objective findings on examination. With consideration of the veteran's complaints of headaches and other symptoms, the RO, in January 1977, granted service connection for organic brain syndrome, residuals basilar skull fracture, with temporal headaches and gait impairment, rated as 10 percent disabling. The record also includes VA outpatient clinical records and records from the Social Security Administration (SSA). These do not contain information reflecting the criteria for a higher rating under old or new criteria. The SSA records are particularly instructive. In December 1976, Jesse A. Lawrence, M.D., acknowledged that the veteran did have some organic problems from his accident, a mild facial palsy and deafness in the left ear; however, he basically had a personality trait disorder and was a "malingerer." In a physical capacities evaluation, Dr. Lawrence reported the veteran could perform heavy work. The December 1976 report of psychologic testing, by Charles T. Kenny, Ph.D., concluded that the veteran was able to read and perform simple arithmetic computations; there was some slight memory problem and difficulty concentrating. His thinking was atypical with a trend toward concreteness and less than average efficiency in solving problems. He was sensitive and unconventional, which occasionally might result in hostile feelings. There might be times when he would have difficulty cooperating with supervisors and coworkers. Several personality traits were probably maladaptive. He was able to use common sense in most situations although on occasion he might depart from socially accepted norms. It was believed that his ability to respond appropriately to ordinary work pressures and to be able to work independently would largely depend on his level of motivation. It was believed that he was not strongly motivated toward employment. His apathy might reflect a poor adjustment to civilian life. Additionally, his personality traits might cause unpleasant situations while on the job. He might have other interpersonal difficulties off the job which would affect his work performance. In December 1977, the veteran was evaluated by Joseph E. Cruppie, M.D., who concluded that the veteran had a great deal of difficulty coping with every day life because he was opinionated, hostile, resentful, demanding, and felt that he was the victim of his accident and the bias of others. He was using his hearing loss and nerve damage in a defensive manner. Additionally, he tended to project, deny and rationalize. He had problems relating to other people. His activities were limited by schizoid personality traits. Even though he could communicate, he tended to misinterpret the words and actions of others. He could read and write. He was competent to manage his own benefits. He would have difficulty in a work situation because of his above mentioned problems. His overall prognosis was poor because of the organic aspect of his problem and the personality trait disturbance. The diagnoses were non-psychotic, organic brain syndrome, post-traumatic; schizoid personality trait; hearing loss, left ear; and partial paralysis, left face. In February 1983, Aldo R. Bevilacqua, M.D. reported that there was no obvious neurological impairment. The doctor reported that the veteran's ability to relate to co-workers and supervisors in a work situation was questionably impaired. He was able to understand and probably remember and carry out one or two step instructions and use basic common sense. He ability to respond appropriately to ordinary work pressures and behave independently in a standardized work situation was questionably impaired. His ability to sustain work and meet quality and production standards was questionably impaired. The veteran did not show any obvious clinical indication of organicity or obvious psychiatric impairment. The doctor commented that there were "too many discrepancies in this case." In March 1983, Nancie Schweikert, M.D., wrote that there was no obvious psychiatric impairment and only a questionable suggestion of organic difficulties. VA clinical notes of February 1984 show that the veteran solicited VA clearance for work at a depot. A physician expressed the opinion that the veteran could work as long as it did not require heavy lifting or climbing. The doctor did not indicate the service-connected disabilities prevented lifting or climbing. In February 1987, Joseph M. Stinson, M.D., reported that the veteran no longer had a facial nerve paralysis, his gait had become normal, and his hearing seemed to have improved. Also in February 1987, another doctor reported that the veteran concentrated better, was not angry or agitated , and demonstrated good memory abilities overall. The improvements would allow the veteran to deal with work effectively and deal appropriately with social interactions at work. The current rating is based on the current extent of the disability, so this discussion will focus on the recent evidence, which is the most probative source of information as to the current extent of the disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). The report of the February 1993 VA examination, shows the veteran complained of hearing loss tinnitus and vertigo. He denied headache, nausea, vomiting, change in vision, or seizures. Physical examination was "unremarkable." The veteran was alert and oriented. Language and other higher cortical functions were intact, except for some difficulty in recall. Neurologic testing disclosed a mild left upper and lower weakness of the left face. The impression was status post basilar skull fracture with minimal residual left seventh cranial nerve, mild to moderate hearing loss, disturbance of equilibrium, some difficulty of recall, otherwise an unremarkable neurological examination. In August 1993, the veteran testified at the RO. He covered numerous issues. Relevant to this discission, he reported decreased IQ. He reported daily headaches. Medication had been prescribed for headache and back pain. He told of depression being diagnosed. A veteran's statements as to what a doctor said are not competent evidence. Warren v. Brown, 6 Vet App 4 (1993). He did not describe symptomatology which would support a higher rating under the old or new criteria. In August 1996, the veteran had a VA examination by Dr. Cummings. Comparing the examination findings with the current rating criteria reveals that the veteran did not have a flattened affect, but was fully engaged in the interview. He was alert, oriented and neatly groomed. There was no circumstantial, circumlocutory, or stereotyped speech; rather, there was no difficulty with word finding, peculiarity of word usage, or difficulty comprehending questions; and vocabulary was above average. There was no evidence of panic attacks or difficulty in understanding complex commands, although he had some difficulty with the instructions in doing serial sevens. There were some deficits on memory testing which were no more than the mild deficits contemplated within the criteria for the current 30 percent rating. The findings did not reflect impairment of short- and long-term memory with deficits such as retention of only highly learned material, or forgetting to complete tasks. Responses to judgment questions were adequate. He had difficulty abstracting similarities initially; however, this is not the definitive impairment of abstract thinking indicative of the next higher rating. There was no evidence of disturbances of motivation or mood or of difficulty in establishing and maintaining effective work and social relationships. Dr. Cummings' August 1996 findings do not approximate the new criteria for rating in excess of 30 percent. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7 (1999). Dr. Cummings diagnosis was organic brain syndrome, not otherwise specified and probable personality disorder. A final diagnosis was deferred pending further testing. The GAF was "50 with serious symptoms and serious impairment of social and occupational functioning." The Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (herein DSM-IV). A GAF of 50 is defined as "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." See Richard v. Brown, 9 Vet. App. 266 (1996). Dr. Cummings explained that the veteran showed a marked disparity between his presentation in the interview and his performance on mental status examination. That could be accounted for either by organic deficits or by poor effort. "An adequate evaluation in this case definitely requires full psychological and neurological testing" "His GAF must be considered tentative pending completion of the above [testing]." Since Dr. Cummings clearly stated that the GAF score was tentative, and further testing was required, the GAF of 50 clearly does not reflect the doctor's opinion as to the extent of the disability. The Board's scrutiny of the report does not disclose any opinion which could be construed as indicating more than the definite impairment associated with a 30 percent rating. The tests were done by Dr. Roper in September 1996. In reference to the new rating criteria, there was no evidence of a flattened affect. The veteran was alert, oriented and generally pleasant. Speech was fluent, rather than circumstantial, circumlocutory, or stereotyped. There was no evidence of panic attacks or difficulty in understanding complex commands. At times he showed good effort and at other times showed unusual responses and poor effort. Occasionally, he appeared to put forth performance that was markedly divergent from his general presentation and suggestive of a conscious attempt to appear impaired. The test results were not felt to clearly reflect his capabilities, but might be considered the lower limit of those capabilities. There were rather unusual errors on memory testing. There results did not indicate impairment of short- and long-term memory such as retention of only highly learned material or forgetting to complete tasks, which would approximate the criteria for the next higher evaluation. There was no evidence of impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. Dr. Roper commented that some of the veteran's errors were quite atypical suggesting poor effort. The personality assessment was invalid due to an acquiescent response set as well as suggestions of over reporting, and thus it was deemed uninterpretable. The doctor concluded that there were strong suggestions that the veteran was not putting forth adequate effort during several portions of testing, perhaps with secondary gain in mind. His intellectual abilities appeared to be at least average, though no consistently shown. Because of "very questionable effort," it was not possible for the doctor to determine the veteran's neuropsychological capabilities based on his performance at that time. It was not possible to rule out some mild residual cognitive sequelae from his head injury in 1971. However, it was the doctor's opinion that the impact of the possible cognitive impairment on the veteran industrial capacity was slight in relation to other contributors, such as a personality disorder. The personality assessment was of limited value because the veteran endorsed symptoms indiscriminately and inconsistently. The diagnosis was possible organic brain syndrome (mild) and personality disorder, not otherwise specified (NOS). The GAF was 60, which corresponds to "moderate difficulty in social, occupational, or school functioning." See Carpenter v. Brown, 8 Vet. App. 240 (1995). Dr. Roper's conclusion that the service-connected organic brain syndrome produced only mild impairment was supported by the limited findings despite the several tests of the veteran's abilities, listed in the report. That mild impairment would not approximate the considerable level of disability required for the higher rating. The GAF score does not support a higher rating as the doctor lucidly explained that the service-connected disability was only a slight component of functioning impaired by a personality disorder and consideration of secondary gain. The report of Dr. Roper's December 1997 VA examination shows the veteran complained of memory loss and mood swings. The doctor noted inconsistent responses, such as the veteran stating that he was socially withdrawn and then describing meeting with friends and participating in family activities. He was also evasive in some responses. When asked about his work history, he said that he last worked for a temporary agency about 7 months earlier, he then said September, he later said August through November. He reported that he worked as a lead man in a warehouse, supervising seven other men. He currently spent time at home reading or watching television. Considering the new rating criteria, there was no evidence of a flattened affect. The veteran was alert, oriented, and quite jocular at times. Speech was normal with an above average vocabulary; not circumstantial, circumlocutory, or stereotyped. There was no evidence of panic attacks or difficulty in understanding complex commands. Impairment of memory was not demonstrated as "marked inconsistencies are seen on memory testing." There was no evidence of impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. It was note that the veteran was irritated with the evaluation stating that he missed a family trip. The findings on Dr. Roper's examination do not approximate the new criteria for a rating in excess of 30 percent. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7 (1999). It was Dr. Roper's impression that the evaluation results were suggestive of average verbal intellectual abilities. As previously reported, the veteran showed inconsistencies across tests. While the intellectual assessment was quite consistent with the previous evaluation, memory testing was highly inconsistent. On other tasks, performance was markedly poor at one point and normal at others. "As such, there are strong indications that the patient was consciously attempting to simulate neuropsychological deficits on the current examination. The patient was also vague on interview and contradicted himself on several occasions, particularly pertaining to his recent employment, raising questions as to the dependability of his reports." The doctor went on that a mild impairment could not be ruled out, as the veteran did show some mild visuospatial impairment, which corresponded to previous testing and the veteran's complaints after the 1971 accident. However, any residual memory or attentional deficits could not be established because or the veteran's poor effort and inconsistent performance. The doctor went on to note that the veteran clearly showed evidence of maladaptive personality traits that led to social and occupational impairments. The diagnosis was cognitive disorder, NOS (mild visuospatial deficits) and personality disorder NOS with anti social traits. The GAF was 66. A GAF from 61 to 70 is for "Some mild symptoms, or some difficulty in social, occupational or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships." DSM-IV. Looking to the old criteria, the doctor's findings support his opinion that the veteran had a mild impairment. This mild impairment would not exceed the definite impairment contemplated under the old criteria and would not approximate the considerable impairment required for a higher rating under those criteria. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7 (1999). Evaluating the report of the January 1998 VA examination by Dr. Cummings, under the new criteria, shows the veteran was alert, oriented, neatly dressed and groomed and in no apparent distress. There was no report of a flattened affect, which is part of the criteria for a higher rating. Contrary to the circumstantial, circumlocutory, or stereotyped speech indicative of the next higher rating, the veteran's speech was spontaneous, coherent and goal oriented. His made few memory responses. He responded to calculation questions slowly or not at all. The examiner concluded that the veteran showed less than optimal effort. The doctor did not indicate that there were memory or thought process deficits consistent with the next higher rating. This report does not reflect findings which would approximate any of the new criteria for a higher rating. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7 (1999). Looking to the old criteria, it is noteworthy that Dr. Cummings reported a GAF score of 51, moderate symptoms and moderate difficulty in social and occupational functioning. The doctor did not express the opinion that the GAF score was due to the service-connected disability. Rather, in the body of the report and again in the diagnosis, the doctor noted the presence of a personality disorder and characterized the organic brain disorder as mild. Under the old criteria, a mild impairment, consistent with Dr. Cummings opinion of the service-connected organic brain disorder, would warrant a 10 percent rating. Neither Dr. Cummings description of the effects of the disorder nor his opinion as to its severity would approximate the considerable impairment of social and industrial adaptability required for a 50 percent rating under the old criteria. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7 (1999). In response to the Board's Remand, in May 1999, Dr. Roper expressed the opinion that the social or industrial impairment attributable to the service-connected disorder would be minimal. Dr. Roper ascribed the major social and industrial impairment to a personality disorder which he felt was not related to the service-connected disability. Dr. Cummings concurred. It was felt that the veteran exaggerated test results and social difficulties. A mild organic brain disorder could not be ruled out but the veteran's personality disorder was the main problem and it was not secondary to the organic brain syndrome. Such a mild disorder with minimal impairment would not meet old or new criteria for a higher rating. Analysis The veteran is competent to say that his service-connected disability is worse. However, the training and experience of the medical personnel put them in a position to make a substantially more probative evaluation as to the extent of the service-connected disability and whether the disability manifestations approximate the criteria for a higher rating. In this case, Dr. Cummings first assigned a GAF score of 50 indicating it to be tentative and contingent of testing. Consequently, that GAF score of 50 can not reasonably be said to reflect the doctor's opinion as to the extent of the disability. In January 1998, Dr. Cummings placed the GAF at 51 for moderate symptoms. However, he clearly identified the veteran's non-service-connected personality disorder as a major factor limiting the veteran's functioning. He specifically expressed the opinion that the service-connected organic brain syndrome was only mild and supported that assessment with findings which reflected a minimal level of impairment due to the organic brain syndrome. In 1999, the doctor again stated that the organic brain syndrome was mild. Dr. Roper has consistently indicated that the personality disorder is the major factor in the veteran's impairment and that the service-connected disability does not cause more than mild impairment. The medical reports are the most probative. They form a preponderance of evidence which establishes that the service-connected organic brain syndrome does not approximate either old or new criteria for a higher rating. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 4.7 (1999). Consequently, an increased rating must be denied. ORDER An increased rating for organic brain syndrome with skull fracture, and temporal headaches, is denied. REMAND The December 1998 Remand asked the physician who examined the veteran's back to express an opinion as to whether it is as likely as not that the veteran's current back disability is the result of injury during service. An explanation of the reasons for the opinion was also requested. The report shows that the doctor performed a detailed examination but did not render the requested opinion. Consequently, the issue of entitlement to service connection for a back disorder must be returned to the RO so that the doctor can amend his report. See Stegall v. West, 11 Vet. App. 268 (1998). When the case was previously before the Board, it was noted that a neurologic gait impairment could be rated separately from the other organic brain syndrome symptoms. However, there was no evidence of a gait disability for many years. On the June 1999 VA examination, the veteran walked with a crouched gait which was slightly antalgic. The diagnosis was chronic low back pain. This raises the question as to whether the gait impairment is a manifestation of a back disorder or the service-connected organic brain syndrome. A physician should also express an opinion on this point. Action on the total disability claim must be deferred. The issues of entitlement to service connection for a back disorder, entitlement to a separate rating for gait disturbance, and entitlement to a total disability rating, for compensation purposes, based on individual unemployability are REMANDED to the RO for the following: The RO should refer the case to Michael D. Calfee, M.D. Dr. Calfee should review the claims folder and express an opinion on the following: Is it as likely as not that the veteran's current back disability is the result of injury during service? Is it as likely as not that the veteran's gait impairment is a manifestation of the service-connected organic brain syndrome; or is it due to his back disorder or other disability? An explanation of the reasons for the opinion should be provided. If Dr. Calfee is not available the case should be referred to another physician. If either physician can not render an opinion without further examination of the veteran, such examination should be scheduled. 2. The RO shall not return the case to the Board until the above action is fully completed by the RO and the VAMC. Following completion of these actions, the RO should review the claims. In accordance with the current appellate procedures, the case should be returned to the Board for completion of appellate review. The Board intimates no opinion as to the ultimate outcome of this case. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. CLIFFORD R. OLSON Acting Member, Board of Veterans' Appeals