Citation Nr: 0004382 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 96-37 677 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a rating in excess of 50 percent for post- traumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 10 percent for bronchial asthma. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Richard Giannecchini, Associate Counsel INTRODUCTION The veteran had active military service from May 1977 to November 1985. A perfected appeal to the Board of Veterans' Appeals (Board) of a particular decision entered by a Department of Veterans Affairs (VA) regional office (RO) consists of a Notice of Disagreement (NOD) in writing received within one year of the decision being appealed and, after a Statement of the Case (SOC) has been furnished, a substantive appeal (VA Form 9) received within 60 days of the issuance of the Statement of the Case or within the remainder of the one-year period following notification of the decision being appealed. The present appeal arises from a July 1996 rating decision, in which the RO service connected the veteran for PTSD and granted a 50 percent disability rating, effective from May 1995. The veteran filed an NOD in November 1996, and the RO issued a supplemental statement of the case (SSOC) in March 1997. The veteran filed a substantive appeal, also in March 1997. Another SSOC was issued in August 1997. The Board notes that the issue with respect to an increased rating for asthma will be discussed in the Remand section of this decision. Furthermore, the Board is aware that in a submitted VA Form 9 (Appeal to the Board of Veterans' Appeals), dated in June 1996, the veteran checked the box marked "No" as to whether he desired a hearing before a member of the Board. However, on the same Form 9, he checked additional boxes indicating that he would appear before the Board in Washington, D.C., and before the Board at the local regional office, only if "I need to go further." In an August 1997 VA Form 21-4138 (Statement in Support of Claim), the veteran requested a hearing before a hearing officer at the VARO in Roanoke. Subsequently, in a VA Form 21-6789 (Deferred Rating Decision), dated in April 1998, the RO hearing officer reported that the veteran had requested a VA pulmonary examination in lieu of a personal hearing. An examination was conducted in July 1998. In view of the foregoing, the Board does not find that any hearing request is currently pending. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. Medical reports from the Mental Hygiene Clinic at the VA Medical Center (VAMC) in Salem have noted the veteran's treatment for PTSD, panic disorders, and agoraphobia; overall global assessment of functioning (GAF) scores were 60-70, noting mild to moderate functional impairment. 3. On VA examination in May 1998, the veteran reported frequent panic attacks and depression, being socially avoidant and withdrawn, and suffering from intrusive thoughts as well as nightmares; clinical evaluation revealed no suicidal/homicidal ideation, hallucinations or delusions, or psychotic abnormalities, with mood anxious and depressed, speech appropriate but restricted in range, insight fair, memory intact, concentration adequate, abstract thinking and judgment intact, and a GAF of 51. 4. Applying the rating criteria in effect prior to November 7, 1996, the evidence has not shown that the ability to establish and maintain effective or favorable relationships with people is considerably impaired, during which the reliability, flexibility, and efficiency levels are so reduced that there is considerable industrial impairment. 5. Applying the rating criteria in effect on and after November 7, 1996, the veteran has not shown 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 difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW The schedular criteria for a disability evaluation in excess of 50 percent for PTSD are not currently met under the rating criteria in effect either before, or on and after, November 7, 1996. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, 4.132, Diagnostic Code 9411 (1996 and 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Basis A review of the claims file reflects that, in May 1995, the veteran submitted a VA Form 21-526 (Veteran's Application for Compensation or Pension) to the RO, in which he filed claims for service connection, in relevant part, for asthma and a panic disorder. In July 1995, the RO received medical records from Ramon Santiago, M.D., dated from October 1994 to June 1995. In particular, these records noted the veteran's treatment for bronchitis and an upper respiratory infection, as well as a panic disorder. The veteran was noted to be taking Albuterol. In August 1995, the RO received medical records from Albert Einstein Hospital, dated from April 1985 to February 1991. These records noted tests conducted of the veteran's cardiovascular system. In February 1996, the veteran underwent a pulmonary examination for VA purposes. He reported a history of asthma since age 19, and complained of episodes of bronchitis and pneumonia one to four times a year. In addition, he reported episodes of exertional asthma and wheezing with exposure to cold, and becoming asthmatic with wheezing on exposure to certain environmental agents. He further reported episodes of shortness of breath one to two times a week, for which he took Ventolin and Azmacort, and also indicated that he suffered from diaphoresis (profuse sweating) before an attack of shortness of breath. The veteran also indicated that he had a two-year history of asbestos exposure. On clinical evaluation, the veteran's lungs demonstrated normal excursion, with no dullness to percussion, and the lung fields were clear, with good air movement. A pulmonary function test (PFT) was normal, and there was also a normal spirometry (lung volume test). The examiner's diagnosis was exertional asthma, asbestos exposure, atopy, and reactive airway disease with exposure to certain environmental agents. That same month, the veteran also underwent a VA examination for mental disorders. He complained of panic attacks which had occurred following a near drowning experience while in the Coast Guard. The veteran reported that he was standing on a disabled boat when it unexpectantly began to sink quickly, and he was sucked underwater. He indicated that he thought he was going to die, but resurfaced and was pulled from the water. During his panic attacks, the veteran stated that he as if he were going to pass out, his heart raced, and his stomach became nervous. In addition, he developed sweaty palms, tingling fingers, and a dry mouth. He reported that he was having the panic attacks daily in 1980, but he began to take Xanax in 1981, and he now only suffered symptoms once a week, and full blown attacks once every two months. The veteran also complained of nightmares which he described as choking dreams, but said that his medical doctor believed this to be sleep apnea. He indicated that these episodes had begun after his near drowning experience. The examiner noted that the veteran's symptoms were consistent with panic disorder, but that he did not meet the criteria for PTSD. His diagnosis was Axis I: Panic disorder; Axis II: Some mixed personality traits; Axis III: Asthma; Axis IV: Mild stressors; Axis V: Current global assessment of functioning (GAF) score, 75. In an April 1996 rating decision, the veteran was service connected for asthma, and was denied service connection for a panic disorder. In a subsequently filed NOD, the veteran reported having received additional treatment for his asthma, and also submitted news articles from the Navy Times and the National Fisherman, documenting his near drowning experience in the Coast Guard. He also requested that he be considered for service connection for PTSD. Thereafter, the RO received a treatment report from Hansa Hussain, M.D., dated in April 1996. Dr. Hussain noted that the veteran was being seen for anxiety, depression, panic attacks, and other paralyzing symptoms, which had come on following his near drowning experience in the Coast Guard. Dr. Hussain further reported that, after considering the veteran's symptoms, history, and entire clinical picture, it was his opinion that the veteran suffered from PTSD. In June 1996, the veteran was administered the MMPI-2 (Minnesota Multiphasic Personality Inventory) test by a VA examiner. The examiner's diagnosis, based on the results of the test, were Axis I: PTSD, mild, as well as panic attacks by history; Axis II: Deferred; Axis III: Bronchial condition; Axis IV: Employment; Axis V: GAF score of 60. The examiner further noted that the veteran demonstrated PTSD in a mild form, and that he also suffered from panic attacks separate from his PTSD. In addition, the veteran underwent a PTSD examination that same month . He reported a history of panic disorder at age 15 that lasted approximately one year, and which then returned in 1984. After his near-drowning experience, the veteran reported that he had begun to experience nightmares that involved him choking, and that these still occurred two to three times a night. The veteran also reported suffering from recurring nightmares of the boat sinking beneath him, intrusive thoughts, and distress associated with any event that reminded him of the stressor incident. Furthermore, the veteran noted that he suffered from irritability, outbursts of anger, and problems sleeping. On clinical evaluation, speech was normal in rate, tone, and volume. There was no loosening of association or flight of ideas. The veteran was noted to be coherent and goal directed, and his mood was described as mildly depressed and anxious most of the time. His affect was full range and appropriate, he had no delusions or obsessions, and there was a lack of auditory, visual or tactile hallucinations. The veteran was noted to experience continued symptoms of PTSD, including avoidance, intrusive thoughts, dreams, nightmares, and hypervigilance. His concentration and cognition were grossly intact, and insight and judgment good. The examiner's diagnosis was Axis I: PTSD and panic disorder; Axis II: Deferred; Axis III: None; Axis IV: Chronic mental illness; Axis V: GAF score of 60. In July 1996, the veteran submitted to the RO a VA Form 9. He noted, with respect to his claim for asthma, that he had been treated for bronchitis as well as other upper respiratory tract infections several times a year. In addition, the veteran reported that sometimes he was on antibiotics for 21 days at a time. Furthermore, he took Albuterol and Azmacort on a constant basis in order to breathe. The veteran noted that the problem had been ongoing for years. Thereafter, the RO received additional medical records from Dr. Santiago, some duplicative, dated from June 1994 to April 1996. In particular, treatment records dated in December 1995 and April 1996 reflected the veteran's treatment for an upper respiratory infection. A treatment record, dated in June 1995, noted the veteran's panic disorder as stable. In a July 1996 rating decision, the RO service connected the veteran for "post-traumatic stress disorder, claimed as panic attacks, competent," and granted a 50 percent disability rating, effective from May 1995. In November 1996, the RO received a statement from the veteran's wife. She noted that the veteran suffered from very vivid nightmares, and that these were based on a fear of dying by choking or heart attack. In addition, the veteran did not like sleeping at another person's home in case the nightmares or sleepwalking occurred. The veteran's wife also reported that the veteran had had problems with maintaining employment since leaving the military because of his fear of his medical condition being discovered and him being fired. This reportedly added to the veteran's anxiety, which made him feel worse. Furthermore, the veteran's wife stated that the veteran went out of his way to avoid being alone, and that he never allowed anyone to place anything in his mouth. She stated that the veteran could be found sometimes crying for no reason and was unable to control his feelings in certain situations, and that he suffered from depression. In January 1997, the veteran underwent a VA pulmonary examination. He noted that his asthma came on with cold weather and that he did have allergies to pollen and dog dander, as well as regular springtime allergies. He reported taking Albuterol and Azmacort as needed, sometimes taking either drug three times a day when he was having difficulty with his breathing. He also reported that he had frequent pneumonia and bronchitis. The examiner noted, on examination, that the veteran was not in respiratory distress. It was also noted that there were no structural changes in the veteran's lungs, and they were clear to auscultation. There were no expiratory or inspiratory wheezes, and all lung fields were clear. A chest X-ray was reported as normal. An associated PFT report noted, in particular, an FEV-1 predicted percentage of 86 and FEV-1/FVC predicted percentage of 82. These were reported as representing normal findings, and there was also a reported normal spirometry. The examiner's diagnosis was history of asthma. In addition, that same month, the veteran underwent a PTSD examination for VA purposes. He reported his previous medical history, and indicated that he had held many jobs since service, his longest being two years as a policeman as well as two years working on a tugboat. The veteran added that his average job had lasted from one to six months and there had been periods of unemployment. He reported that his loss of jobs had been due to panic attacks, and that he would always quit a job and was never fired. The veteran's chief complaints were panic attacks and an inability to go anywhere by himself. He indicated that he was nervous all the time and suffered from two panic attacks a week. Furthermore, the veteran denied intrusive distressing thoughts or recollections of his near-drowning experience in the Coast Guard, although being around something that reminded him of the event would upset him very much. He also reported being depressed a great deal and suffering from crying spells, as well as tending to feel hopeless, lacking in energy, and having very limited interests. The veteran reported getting about four to five hours of sleep a night, and suffering from one to two nightmares a week. On clinical evaluation, the veteran was alert, oriented, cooperative, and responsive. His mood was anxious and dysphoric. He appeared tense, had sweaty hands, and displayed limited smiling and laughing. Speech was normal, affect was somewhat restricted, and psychomotor activity was within normal limits. The veteran denied suicidal thoughts, hallucinations, or delusions, and was not found to be psychotic. Insight was fair, and immediate memory was mildly impaired, while recent and remote memories were intact. Concentration was adequate, with abstract thinking and judgment being intact. The examiner's diagnosis was Axis I: PTSD; Axis II: No diagnosis; Axis III: None; Axis IV: None; Axis V: GAF score of 55. The veteran was noted to have moderate symptoms of PTSD, with moderate social and occupational functioning. In March 1997, the veteran submitted Statement in Support of Claim in which he reported that, prior to his January VA pulmonary examination that morning, he had received emergency medical treatment for a severe asthma attack. He also reported that he had been on daily inhalation therapy for over 10 years. Furthermore, the veteran submitted a copy of his Albuterol inhaler medical prescription which noted "Use 2 puffs every 4-6 hours as needed." In June 1997, the RO received VAMC Salem medical records, dated from January 1997 to June 1997. A February 1997 treatment record noted the veteran's complaints of congestion and asthma attacks at night. He reported coughing up "black stuff" and using an inhaler. The examiner's diagnosis was bronchitis. Treatment records from the Mental Hygiene Clinic dated in March, May, and June 1997 noted the veteran was without suicidal/homicidal ideations or psychotic thoughts. The diagnoses included PTSD and panic attacks, with GAF scores of 65-70. In addition, the June 1997 record noted the veteran's report that, overall, things were going to his satisfaction regarding his family, his finances, and his studies. Furthermore, various treatment records noted the veteran's complaints of increased anger and irritability. He was noted to be meeting with a VA anger control group. In August 1997, the veteran submitted a statement in support of his claim to the RO, in which he reported that, while in the Coast Guard, he had fought a number of ship fires and, in doing so, he had breathed in much smoke. In addition, he reported that, while combating these fires, he had never worn any protective respirator equipment. He also reported that he had never had any problems with his lungs prior his near- death drowning experience. In an additional statement in support of his claim that same month, the veteran reported that he had to use his medications daily, and that he suffered asthmatic attacks on a daily basis. In October 1997, the RO received VAMC Salem treatment records, dated from June 1997 to September 1997. An August 1997 treatment record noted the veteran's complaints of cough and cold symptoms for a few days. The veteran reported coughing up brown/black sputum. The examiner's impression was bronchitis. A treatment summary, also dated in August 1997, from the treating VA psychologist for the veteran's anger control group, noted that the veteran suffered from, among other things, PTSD, panic disorder with limited agoraphobia, and recurrent major depressive episodes. The psychologist also opined that the veteran was not suited for employment that involves a great deal of stress. Mental Hygiene Clinic notes, dated in June and July 1997, noted continued diagnoses of PTSD, with no findings of psychotic behavior or suicidal/homicidal ideation. The June 1997 note reflected a GAF score of 70. In November 1997, the RO received a copy of a statement from a nurse practitioner who was overseeing the veteran's care at the VAMC Salem. It was noted that the veteran used an Albuterol inhaler daily, two puffs four times a day, to manage his asthma. In May 1998, the veteran again underwent a VA PTSD examination. He reported that he was unemployed, and had last worked in 1995. He said he was currently in nursing school, and had previously dropped out of a program to become a physician's assistant because it became too stressful. His chief complaints were agoraphobia, anger, forgetfulness, bad nightmares, and paranoia. The veteran also reported frequent panic attacks and feeling depressed all the time. He denied crying spells, suicidal/homicidal ideation, or hallucinations or delusions. He indicated that he was suspicious and distrustful of people, as well as being hypervigilant. He also reported that he tended to be socially avoidant and withdrawn, and reported not having any friends. On clinical evaluation, the veteran's dress, grooming, and hygiene were good. He was alert and fully oriented. Behavior was appropriate, cooperative, and responsive. His mood was anxious and depressed, and he appeared tense and restless. Speech was appropriate but restricted in range. Psychomotor activity was within normal limits, and there were no psychotic abnormalities or abnormalities in perception, thinking, or thought content. Insight was fair, memory intact, and concentration adequate, with abstract thinking and judgment intact. The examiner's impression was Axis I: PTSD, panic disorder with agoraphobia; Axis II: None; Axis III: None; Axis IV: None; Axis V: GAF score of 51 (moderate difficulty in social and occupational functioning). In July 1998, the RO received VAMC Salem medical records, dated from September 1997 to July 1998. These records noted the veteran's continued treated for PTSD, panic attacks, and agoraphobia, as well as his participation in anger control counseling. His overall GAF scores were noted in the range of 65-70. Additionally, an October 1997 treatment note reflected a diagnosis of PTSD, panic disorder with mild agoraphobia, and severe depression, with a GAF score of 45. A January 1998 treatment note reflected the veteran's report that his panic attack symptoms consisted of dizziness, increased heart rate, difficulty breathing, and a feeling of impending doom. He reported that his panic attack symptomatology had been milder and less frequent recently. A May 1998 treatment report noted that the veteran had just found a part-time job at Roanoke Memorial Hospital in conjunction with his studies as a nursing student. The veteran was reported to describe himself as continuing to do well. With respect to asthma, a treatment note, dated in January 1998, reflected that, over the last five to six months, the veteran had made three visits to the emergency room with increased shortness of breath, and had been treated with antibiotics. The veteran reported having asthma, but indicated that he had never been tested. The examiner's assessment was increased shortness of breath/dry cough with questionable asthma exacerbation versus anxiety attacks. In December 1998, a treatment note reflected that the veteran had been seen in the emergency room for continued upper respiratory infection symptoms. Additional treatment notes reflected complaints of shortness of breath and wheezing, with several diagnoses of bronchitis. The veteran was reported using Albuterol and Azmacort inhalers. In July 1998, the veteran underwent a VA respiratory examination. He reported that his asthma had not improved, and that he had presented at the emergency room at least five times with breathing problems. The examiner, a nurse practitioner, noted that the veteran had been diagnosed with exercise-induced asthma. She also reported that the veteran's PFT findings were post-bronchial, since the veteran had taken his inhalers prior to the test. On clinical evaluation, palpation of the lungs showed decreased tactile fremitus, with hyperresonance on percussion. The veteran was reported to have distant breath sounds throughout his lung fields. In addition, he had decreased vocal resonance and there was transient wheezing at the base of both lungs. An associated chest X-ray was reported to reveal a stable chest. It was also noted that a spirometry test had been normal. The examiner's impression was exercise-induced asthma. II. Analysis The veteran has submitted a well-grounded claim for an increased rating within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). That is, the Board finds that he has submitted a claim which is plausible. This finding is based on the veteran's assertion that his service- connected PTSD is more severe then previously evaluated. See Jackson v. West, 12 Vet.App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet.App. 629 (1992). The Board is also satisfied that all relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained, and that no further assistance is required to comply with the duty to assist, as mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based upon average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 3.102, 4.3, 4.7 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet.App. 55, 58 (1994); 38 C.F.R. §§ 4.1, 4.2 (1999). During the course of this appeal, substantive changes were made by regulatory amendment to the schedular criteria for evaluating mental disorders, as set forth in 38 C.F.R. §§ 4.125-4.132. See 61 Fed. Reg. 52,695-52,702 (1996). These changes became effective on November 7, 1996. See 38 C.F.R. § 4.130 (1999). The RO applied the revised criteria in its evaluation of the veteran's service-connected PTSD, and the veteran was notified of its decision in a March 1997 SSOC, which, at that time, continued his disability rating at 50 percent. Where the law or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet.App. 308, 312-313 (1991). See also Baker v. West, 11 Vet.App. 163, 168 (1998); Dudnick v. Brown, 10 Vet.App. 79 (1997) (per curiam order). In reviewing this case, the Board must therefore evaluate the veteran's psychiatric disorder under both the old and current regulations to determine whether he is entitled to an increased evaluation under either set of criteria. Prior to the regulatory changes, the veteran's psychiatric disorder had assigned to it a 50 percent rating under 38 C.F.R. § 4.132, Diagnostic Code 9411, "Post-traumatic stress disorder," as in effect before November 7, 1996. Based upon that regulatory scheme, the severity of a psychiatric disability was based upon evaluating how the actual symptomatology affected social and industrial adaptability. 38 C.F.R. § 4.130. Evidence of social inadaptability was evaluated only as it affected industrial adaptability. 38 C.F.R. § 4.129. Two of the most important determinants of disability were time lost from gainful work, and decrease in work efficiency. The condition of an emotionally sick veteran with a good work record was not to be undervalued, however, nor his condition overvalued based on a poor work record not supported by the psychiatric disability picture. In evaluating disability from psychotic disorders, it was necessary to consider the frequency, severity, and duration of previous psychotic periods, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.130. Under DC 9400, pre-November 7, 1996, a 100 percent rating was assigned under these criteria: "The attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. Demonstrably unable to obtain or retain employment." A 70 percent rating was assigned where the ability to establish and maintain effective or favorable relationships with people was severely impaired, during which the psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A 50 percent rating was to be assigned where the ability to establish and maintain effective or favorable relationships with people was considerably impaired, during which the reliability, flexibility, and efficiency levels were so reduced that there was considerable industrial impairment. See 38 C.F.R. § 4.132, DC 9411 (1996). The Board also notes that the criteria in 38 C.F.R. § 4.132, DC 9411, for a 100 percent rating are separate and independent bases for granting a 100 percent rating. See Johnson v. Brown, 7 Vet.App. 95, 97 (1994). The intended effect of the newly effective regulatory changes is to update the portion of the rating schedule that addresses mental disorders, and to ensure that it uses current medical terminology and unambiguous criteria, and reflects medical advances that have occurred since the previous review of regulatory criteria. When evaluating a mental disorder under the new regulatory scheme, the RO shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 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 (1999). Under the current, post-November 6, 1996, criteria, under which the veteran remains assigned a 50 percent evaluation, such a rating requires 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 difficulty in establishing and maintaining effective work and social relationships. For higher ratings under the current criteria, a 70 percent evaluation requires 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 an inability to establish and maintain effective relationships. For a disability rating of 100 percent, the veteran must show total occupational and social impairment, due to such symptoms as: gross impairment in though 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. See 38 C.F.R. § 4.130 (1999). As noted above, in evaluating the veteran's disability under section 4.132 (old criteria), two of the most important determinants of disability are time lost from gainful work and a decrease in work efficiency. See section 4.130. In this respect, on VA examination in May 1998, the veteran reported himself as having been unemployed since 1995. His chief complaints were agoraphobia, anger, forgetfulness, bad nightmares, and paranoia. He reported feeling nervous and depressed all the time. There were no findings of psychotic abnormalities. The examiner diagnosed the veteran with PTSD, as well as panic attacks and agoraphobia. He assigned the veteran a GAF score of 51. The Board notes that a GAF score of 51 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). See Quick Reference to the Diagnostic Criteria from DSM-IV, Washington, DC, American Psychiatric Association, 1994. Thereafter, on a follow-up visit to the VAMC Salem Mental Hygiene Clinic that same month, May 1998, the veteran reported he had found a part-time job in Roanoke Memorial Hospital in conjunction with his studies as a nursing student. He also reported himself as continuing to do well. The veteran was assigned a GAF of 65-70, indicative of moderate to mild symptoms. Thus, when the Board considers this most current evidence of record, along with other VAMC Salem Mental Hygiene Clinic reports, which note overall GAF scores ranging from 60-70, we find that the preponderance of the evidence does not establish that the veteran's ability to establish and maintain effective or favorable relationships with people is severely impaired, or that psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. We are cognizant that, in October 1997, the veteran was reported to suffer from PTSD, panic disorder with mild agoraphobia, and severe depression, and his condition was assigned a GAF score of 45, reflective of serious impairment. However, we find, in reviewing the record, that there was not another instance in which the veteran's disability was determined to be serious, or other than mild or moderate, in degree. Thus, when the Board considers all the evidence of record, we find the veteran's PTSD does not warrant an increase to 70 percent under the old rating criteria in effect prior to November 7, 1996. See 38 C.F.R. § 4.132, DC 9411 (1996). With respect to the rating criteria on and after November 7, 1996, when evaluating a mental disorder under the new regulatory scheme, the RO shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the veteran's capacity for adjustment during periods of remission. When we consider the evidence of record, as is noted above, we find that a preponderance of the evidence is also against a rating to 70 percent or higher. As noted above, during the May 1998 VA examination, on clinical evaluation, the veteran's mood was anxious and depressed, and there were no suicidal/homicidal ideations. There were no psychotic abnormalities, or abnormalities in perception, thinking, or thought content. Insight was reported as fair, memory was intact, and concentration adequate. Abstract thinking and judgment were also intact. The veteran has currently started a part-time job at a hospital, in association with his nursing studies. He has reported himself as continuing to do well. Previously, in June 1997, the veteran report that, overall, things were going to his satisfaction regarding family, finances, and his studies. While the Board does not doubt that the veteran does occasionally suffer periods in which his PTSD becomes more disabling than is currently rated, given the overall evidence of record, including, as noted above, a predominant number of GAF scores in the range of 60-70 reflecting mild to moderate impairment, we find that the preponderance of the evidence is against an increased rating to 70 percent. See 38 C.F.R. § 4.130, DC 9411 (1999). That is, the veteran's service-connected PTSD is not reflective of 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 an inability to establish and maintain effective relationships. Furthermore, given that the veteran does not warrant an increased rating to 70 percent, the Board logically concludes that the evidence also does not support a total (100 percent) schedular rating, under either the old or the new schedular criteria. We have considered the applicability of the benefit-of-the- doubt/reasonable-doubt doctrine, which provides that, where the Board finds an approximate balance of positive and negative evidence as to the merits of the claim, the benefit of the doubt shall be given to the veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (1999). However here, while we are sympathetic to the veteran's claim, the evidence in this case preponderates against an increased rating, so that doctrine does not come into play. We also recognize that the Court of Appeals for Veterans Claims has addressed the distinction between a veteran's dissatisfaction with the initial rating assigned following a grant of entitlement to compensation, and a later claim for an increased rating. See Fenderson v. West, 12 Vet.App. 119, 126 (1999). The Court noted that the rule from Francisco v. Brown, supra, as to the primary importance of the present level of disability, is not necessarily applicable to the assignment of an initial rating following an original award of service connection for that disability. Rather, the Court held that, at the time of an initial rating, separate ratings can be assigned for separate periods of time based upon the facts found - a practice known as assigning "staged" ratings. In view of the Court's holding in Fenderson, the Board has considered whether the veteran was entitled to a "staged" rating for his service-connected disability, as the Court indicated can be done in this type of case. As noted above, the veteran submitted his claim for PTSD in May 1995. The veteran's current disability rating of 50 percent has been effective from that date. Upon reviewing the longitudinal record in this case, we find that, at no time since the filing of the veteran's claim for service connection, has his PTSD been more disabling than as currently rated under the present decision. ORDER Entitlement to an increased rating for PTSD is denied. REMAND As to the claim relating to bronchial asthma, the veteran has submitted a well-grounded claim within the meaning of 38 U.S.C.A. § 5107(a). See Murphy; Gilbert, supra. That is, the Board finds that he has submitted a claim which is plausible. This finding is based in part on the veteran's assertion that his service-connected bronchial asthma is more severe than previously evaluated. See Jackson, supra. The Board notes that, in an August 1998 rating decision, the veteran's bronchial asthma disability was increased from a noncompensable rating to 10 percent, with an effective date from October 1996. In reviewing the veteran's service medical records, we note that he was diagnosed with exertional bronchospasm/asthma as a result of cold weather. As is reported in the Factual Basis, supra, the veteran was subsequently diagnosed with this disorder on VA examination in February 1996, some ten years following his separation from active service. At that time, the veteran reported, among other things, a two-year history of asbestos exposure, and he complained of wheezing with exposure to certain hydrocarbons that he used in conjunction with his work as a mechanic. An associated PFT at that time was normal, as was a spirometry test. In addition to the diagnosis of exertional asthma, the examiner also reported that the veteran suffered from reactive airway disease with exposure to certain environmental agents. Since that time, VAMC Salem medical records have documented the veteran's treatment for bronchitis and upper respiratory infections. He has been prescribed Albuterol and Azmacort as needed. We are cognizant that in none of the medical records has a physician clinically diagnosed the veteran with bronchial asthma or determind that he suffers from asthmatic attacks. Moreover, during a VA examination in January 1998, a physician's assessment noted increased shortness of breath/dry cough with questionable asthma exacerbation versus anxiety attacks. We note that the only current evidence reflective of the veteran's treatment for asthma is a November 1997 statement from a VAMC Salem nurse practitioner. Furthermore, a nurse practitioner also conducted the veteran's most current VA examination, in which he was diagnosed with exertional asthma. No PFT findings were reported, given that the veteran had taken bronchodilators prior to the pulmonary function test. We intend no criticism of the findings reported by the nurse practitioners. Our concern is that we must render a decision based upon the medical evidence, and it is not clear whether the veteran is affected by respiratory disorders not etiologically related to his service-connected disability. The Board thus finds that there is conflicting medical evidence as to whether the veteran is currently suffering from bronchial/exertional asthma, or whether he suffers from some other form of respiratory distress for which he might not necessarily be service connected, even though he does use inhalation and bronchodilator therapy. Therefore, given this finding, and the need for a current VA pulmonary examination by a VA medical doctor, to include a current pulmonary function test, we believe additional development with respect to the veteran's claim is needed. In view of the above, the case is REMANDED to the RO for the following action: 1. The RO should obtain the names and addresses of all medical care providers (VA or non-VA), if any, who have treated the veteran for bronchial asthma since July 1998. The RO should request that the veteran furnish signed authorizations for release to the VA of private medical records in connection with each non-VA source identified. The RO should attempt to obtain any such private treatment records and any additional VA medical records not already on file, which may exist, and incorporate them into the claims folder. 2. The veteran should be scheduled for a VA pulmonary examination to determine the current level of severity of his service- connected bronchial asthma condition. The claims folder should be made available to the examiner for review in conjunction with the examination, and the examiner should acknowledge such review in the examination report. All indicated studies should be performed, including a pulmonary function test, and all clinical findings reported in detail. In particular, the examiner should express an opinion as to whether the veteran's complaints of respiratory distress, noted in VAMC Salem treatment records as bronchitis and upper respiratory infections, are, as least as likely as not, related to his service-connected bronchial asthma. If any other pulmonary diagnosis is indicated, the examiner should so state. The examiner should support his or her opinion by discussing medical principles as applied to specific medical evidence in the veteran's case. 3. The RO should then take adjudicative action on the veteran's claim for a rating in excess of 10 percent for bronchial asthma. The veteran's disability should be evaluated with consideration of the rating criteria under the provisions of 38 C.F.R. § 4.97, DC 6602 effective prior to October 7, 1996, and effective on and after October 7, 1996 for bronchial asthma. Thereafter, a rating decision should be issued pursuant to Karnas, above. 4. If the benefits sought are denied, the veteran and his representative should be provided with a SSOC notifying them of all the pertinent laws and regulations used in the adjudication of the veteran's claim, in particular 38 C.F.R. § 4.97, DC 6602 (1999). After the veteran and his representative have been given an opportunity to respond to the SSOC, the claims folder shall be returned to the Board for further appellate review. No action is required of the veteran until he receives further notice. The purpose of this remand are to procure clarifying data and to comply with governing adjudicative procedures. The Board intimates no opinion, either legal or factual, as to the ultimate disposition of this appeal. The veteran 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. ANDREW J. MULLEN Member, Board of Veterans' Appeals