Citation Nr: 0305773 Decision Date: 03/26/03 Archive Date: 04/03/03 DOCKET NO. 98-19 556A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an increased disability rating for the residuals of post-gastric resection, with gastric reflux, currently rated as 20 percent disabling. 2. Entitlement to an increased disability rating for diastasis recti, currently rated as noncompensable. 3. Entitlement to an increased disability rating for post- traumatic stress disorder, currently rated as 30 percent disabling. (The issues of entitlement to service connection for the postoperative residuals of a deviated nasal septum and entitlement to a total rating based on individual unemployability due to service-connected disabilities will be the subject of a later decision.) REPRESENTATION Appellant represented by: John Stevens Berry, Attorney at Law ATTORNEY FOR THE BOARD Michael A. Pappas, Counsel INTRODUCTION The veteran-appellant had active service from July 1941 to June 1945. When this matter was last before the Board of Veterans' Appeals (Board) in September 2002, it was remanded to the Department of Veterans Affairs (VA) Regional Office in Lincoln, Nebraska (RO) for additional development. As will be explained below, the issues considered herein have been appropriately developed and are now ready for appellate review. The Board is undertaking additional development on the issue of entitlement to service connection for the postoperative residuals of a deviated nasal septum, pursuant to authority granted by 38 C.F.R. § 19.9(a) (2002). When it is completed, the Board will provide notice of the development as required by Rule of Practice 903. 38 C.F.R. § 20.903 (2002). The issue of entitlement to a total rating based on individual unemployability due to service-connected disabilities will be deferred pending that development. After giving the notice and reviewing your response to the notice, the Board will prepare a separate decision addressing these issues. FINDINGS OF FACT 1. All evidence necessary for review of the issues considered on the merits herein on appeal has been obtained, and VA has satisfied the duty to notify the veteran of the law and regulations applicable to the claims considered herein and the evidence necessary to substantiate those claims. 2. The veteran's residuals of post-gastric resection, including gastric reflux, although symptomatic of constant but mild discomfort in the periumbilical region; very infrequent (twice a year) episodes of dumping syndrome; and gastric reflux twice per week, well-controlled by Mylanta; is not productive of moderate symptoms of epigastric distress accompanied by mild circulatory symptoms after meals with diarrhea and weight loss. 3. The veteran's diastasis recti is not productive of a small wound, not well supported by belt under ordinary conditions, or a healed ventral hernia or post-operative wounds with weakening of abdominal wall and indication for a supporting belt. 4. The veteran's service-connected post-traumatic stress disorder, which is manifested by sleep disturbance, nightmares, flashbacks, depressed mood, and mild memory loss, is not shown to be productive of more than mild to moderate occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The schedular criteria for a disability rating in excess of 20 percent for the residuals of a post-gastric resection, with gastric reflux, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.110-4.113, 4.114, Diagnostic Code 7308 (2002). 2. The schedular criteria for a compensable disability rating for diastasis recti have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.110-4.113, 4.114, Diagnostic Code 7339 (2002). 3. The schedular criteria for a disability rating in excess of 30 percent for post-traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Codes 9411, 9440 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran is seeking entitlement to an increased disability rating for the residuals of post-gastric resection, currently rated as 20 percent disabling, entitlement to an increased disability rating for diastasis recti, currently rated as noncompensable, and entitlement to an increased disability rating for post-traumatic stress disorder, currently rated as 30 percent disabling. Essentially, he contends that these disorders are far more disabling than is contemplated by the disability ratings assigned. In the interest of clarity, the Board will initially address the matter of whether this case has been appropriately developed for appellate purposes. The Board will then analyze each of the veteran's claims. Veterans Claims Assistance Act of 2000 As noted in the January 2001 decision of the Board, the October 2001 Joint Motion for Partial Remand filed before the United States Court of Appeals for Veterans Claims (Court), a September 2002 remand of the Board, an October 2002 letter to the veteran from the RO, and the December 2002 supplemental statement of the case, there has been a significant change in the law during the pendency of this appeal. On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). This law eliminated the former statutory requirement that claims be well grounded. This law also redefined the obligations of VA with respect to the duty to assist and includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. Regulations implementing the VCAA have been enacted. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) [codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a)]. The Board has carefully considered the provisions of the VCAA and the implementing regulations in light of the record on appeal, and for reasons expressed immediately below finds that the development of the issues has proceeded in accordance with the provisions of the law and regulations. There is no question as to substantial completeness of the veteran's application for VA benefits. See 38 U.S.C.A. § 5102 (West 2002). In filing his claim of entitlement to increased ratings in June 1997, the veteran clearly identified the disabilities in question, the bases for the claims and the benefits sought. The claim appeared substantially complete on its face. The former well-grounded claim requirement The current standard of review requires that after the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2002). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The RO implicitly determined that the veteran's claims for increased evaluations were well grounded, essentially considering the veteran's claims under the current standards of review. See the October 1998 and October 1999 rating decisions. The Board finds, therefore, that it can consider the substance of the veteran's appeal under the current standards of review without prejudice to him. See Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. Notice The VCAA requires VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103 (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The veteran was notified of the information necessary to substantiate his claim by means of the discussions in the October 1998 rating decision, the October 1999 rating decision, the November 1998 statement of the case, the December 1999 statement of the case, the January 2001 decision of the Board, and December 2002 supplemental statement of the case. In those decisions, the veteran was advised that the evidence did not demonstrate the requisite pathology for a higher evaluation for each of the increased rating disabilities at issue herein. A letter from the RO dated in October 2002 specifically advised the veteran of his rights and responsibilities under the VCAA. In that letter and in the December 2002 supplemental statement of the case, the veteran was advised what evidence he should submit and that VA would assist him in obtaining that evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Based on the specific notice provided to the veteran, the Board has concluded that VA has no outstanding duty to inform the veteran that any additional information or evidence is needed. Duty to assist The Board finds that reasonable efforts have been made to assist the veteran in obtaining evidence necessary to substantiate his claim, and that there is no reasonable possibility that further assistance would aid in substantiating his claim. The RO obtained or attempted to obtain the veteran's VA and private treatment records as they were identified by the veteran. The veteran was asked on several occasions to submit the names of any private or VA medical providers who had treated him for the claimed disorders, along with completed authorizations, so that the RO could obtain any records identified. The veteran responded to these requests, and the available evidence was obtained. In August 2002 and December 2002, the veteran stated that there was no further evidence to submit. It does not appear that there are any additional pertinent treatment records to be requested or obtained. Finally, the Board notes that the veteran has been afforded specific VA examinations for the purpose of determining the extent of disability resulting from his service-connected post-traumatic stress disorder, gastric disorder, and diastasis recti. There has been offered no evidence to indicate that additional examination would provide the demonstration of greater pathology than is already shown in the existing examination reports. In this case, the Board finds no basis to obtain additional medical examination. 38 C.F.R. § 3.159(c)(4) (2002). Accordingly, there is sufficient evidence to decide this claim. The veteran was advised of the evidence he needed and was provided ample opportunity to submit or identify additional evidence or argument in support of his claim. Analysis Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In addition, the evaluation of the same disability under various diagnoses, and the evaluation of the same manifestations under different diagnoses, are to be avoided. C.F.R. § 4.14. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Residuals of Post-gastric Resection, with Gastric Reflux Service connection first came into effect for chronic ulcer of the duodenum by an August 1945 rating decision, in which there was assigned a 30 percent disability rating effective June 15, 1945. As is documented in the claims file, over the years the veteran's symptomatology due to his gastrointestinal disability has varied in severity, and he had several operations involving his gastrointestinal tract to treat his duodenal ulcer, including a subtotal gastric resection. Correspondingly, the veteran's disability rating has fluctuated regularly since service connection was granted. A December 1970 rating decision assigned a 20 percent disability rating, effective April 1, 1971. This 20 percent disability rating has remained in effect ever since. In an October 2001 rating decision, service connection was granted for gastric reflux as secondary to and evaluated together with post-gastric resection as 20 percent disabling. An August 1998 VA radiology report of the upper gastrointestinal tract revealed the following: Zenker's diverticulum in the upper esophagus; hiatal hernia with reflux; and postoperative changes of a partial gastrectomy with no evidence of any stomach ulcers. A contemporaneous VA general medical examination report includes a review of the above-referenced radiology report and the relevant medical history. The veteran denied melena, nausea, vomiting, diarrhea, constipation, episodes of colic, fever, chills, epigastric pain, reflux symptoms, and there were no signs of anemia. A weight loss of 10 pounds in one year was reported, but appetite was good. An examination of the abdomen revealed no tenderness or rebound. The diagnoses included the following: Zenker's diverticulum; reflux esophagitis; hiatal hernia; partial gastrectomy from Billroth type I surgery. A September 1999 VA general medical examination report includes an examination of the abdomen, which was soft and flat with healed surgical scars. The impression included status post peptic ulcer disease, hiatal hernia, and a Billroth I anastomosis. A September 1999 gastrointestinal examination report recounts the relevant medical history. The veteran's primary treatment included antacids and Metamucil. Vomiting, passing melena, hematemesis, colic, and abdominal distention were denied, but the veteran complained that he experienced dumping syndrome twice a year about a half-hour after eating. No anemia was detected and his weight has been stable. He complained of constant discomfort in the periumbilical region, although abdominal pain was not described as being a problem. There was no recent history of gastritis. The diagnoses were as follows: peptic ulcer disease; status post-gastric resection; status post perforated ulcer; present condition Billroth I anastomosis; and hiatal hernia with reflux esophagitis. There was submitted a statement by Dr. R.K.R. dated in August 2000 in which it was noted that the veteran was a patient of Dr. R.K.R. In the statement, Dr. R.K.R. opined that there is "at the very least a possibility that the veteran's recurrent irritable bowel condition and acid reflux were directly related to the post-gastric resection that was necessitated by [the veteran's] peptic ulcer disease he developed while in the military service." The veteran was seen on a VA outpatient basis in July 2000 with a chief complaint of depression. The veteran was noted to be complaining of depression but no suicidal ideation. He had no other complaints. It was noted that he also had gastroesophageal reflux disease which was deemed stable with no flare-ups. A history of several other disorders, including other gastrointestinal disorders, was noted. Following examination, the diagnoses were constipation and gastroesophageal reflux. Treatment included the refill of medications. The veteran was scheduled for follow-up with a complete blood count in six months. In October 2000, the veteran underwent another VA gastrointestinal examination. In the report of the examination, the veteran stated that what had changed since his last examination in August 1999 was that he was having more acid reflux. He noted that certain foods seemed to bother him more than they did in 1998. He had no vomiting, no hematemesis, and no melena. His current treatment was Mylanta, as needed for the acid reflux that seemed to control it "pretty well." He stated that he had to use it once or twice a week. He also used Metamucil for constipation. He reported a daily bowel movement and no further problems with this. He denied nausea, vomiting, distension, or other gastric symptoms. It was note that the veteran had weight gain since 1998. In August 1998, his weight was 150 pounds, and it was 167 at this examination. There were reported no signs of anemia. Following examination, the diagnoses were: Gastric reflux, increase in symptoms since 1998, controlled with Mylanta; History of Zenker's diverticulum; History of reflux esophagitis; History of hiatal hernia; and Status post partial gastrectomy from Billroth Type I surgery. VA outpatient treatment records note that the veteran was seen in December 2000 for a follow-up visit with laboratory studies. He denied any complaints. He was noted to have a history of chronic constipation. His weight was noted to be 168.7 pounds. His complete blood count laboratory study was noted to be normal. The diagnosis was chronic constipation. VA outpatient treatment records note that the veteran was seen in December 2001 for a follow-up visit. There was noted to be no heartburn. His weight was noted to be 167.5 pounds. His complete blood count laboratory study was noted to be normal. The pertinent diagnosis was gastroesophageal reflux disease. The remaining evidence consists of the veteran's statements contending that he is entitled to an increased disability rating. At the outset, the Board notes that in applying alternative diagnostic codes, the Board must adhere to the language of 38 C.F.R. § 4.114, which directs that: [r]atings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The veteran's disability rating is rated under 38 C.F.R. §4.114, Diagnostic Code 7308, which provides the guidelines for evaluating postgastrectomy syndromes, and provides that a maximum 60 percent disability rating is for application when there are severe symptoms, associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. A 40 percent disability rating is appropriate when there are moderate symptoms, characterized by less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss. The minimum 20 percent disability rating is for application when there are mild symptoms, characterized by infrequent episodes of epigastric distress with characteristic mild circulatory symptoms or continuous mild manifestations. The Board finds that a disability rating in excess of 20 percent under this diagnostic code is not warranted, as there is no medical evidence of moderate symptoms of epigastric distress accompanied by mild circulatory symptoms after meals with diarrhea and weight loss. Although the veteran has complained in the past of constant discomfort in the periumbilical region, this discomfort does not produce significant pain and appears to be mild in nature. The only symptoms accompanying this discomfort consist mostly of dumping syndrome twice a year. There has been shown no signs of anemia, and in fact, the veteran has been shown to gain, not lose, weight over the years. Overall, the veteran's symptomatology more closely approximates the schedular criteria for a 20 percent rating. As such, the preponderance of the evidence is against the veteran's claim for a disability rating in excess of 20 percent. The veteran has considered rating the veteran under other relevant alternative codes. However, as there is no evidence of adhesion of the peritoneum, gastric or duodenal ulcers, gastritis, or operative complications, Diagnostic Codes 7301, 7304, 7305, 7306, 7307, 7309, 7310, and 7348 are inapplicable. Although service connection for gastric reflux has been established as related to the veteran's post-gastric resection, it has not been shown to allow a greater evaluation than the 20 rating provided under diagnostic code 7308 for post-gastric resection, which continues to reflect the predominant disability. Significantly, the veteran's gastric reflux occurs no more than twice per week, and is well-controlled with Mylanta. The veteran has been shown to have a history of hiatal hernia, and a history of reflux esophagitis, as well as complaints of an irritable bowel condition. Service connection is not in effect for these disabilities, however, and it is not shown that they are otherwise related to the veteran's service-connected gastrointestinal disability, including gastric reflux. In conclusion, the preponderance of the evidence is against the veteran's claim for an increased evaluation for his gastrointestinal disorder. The schedular criteria for a disability rating in excess of 20 percent for the residuals of a post-gastric resection, with gastric reflux, have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.14, 4.110-4.113, 4.114, Diagnostic Code 7308. Diastasis Recti A December 1970 rating decision granted service connection for diastasis recti as secondary to surgery performed for the veteran's service-connected post-gastric resection. A noncompensable disability rating was assigned, effective December 15, 1970, which has remained in effect ever since. In his variously dated written statements, the veteran contends he is entitled to a compensable rating for this disability. Turning to the relevant medical evidence, an August 1998 VA general medical examination report includes an examination of the abdomen, revealing it to be soft, with no tenderness, rebound, hepatosplenomegaly, or masses. There was a well- healed median incision scar. A September 1999 VA general medical examination report also includes an examination of the abdomen, which was observed to be soft and flat. There was a healed paramedial scar from the xiphoid to below the level of the umbilicus, and in the mid-portion of the scar there appeared to be a defect consistent with incisional hernia. There was also a scar in the right lower quadrant consistent with an appendectomy. There were no abdominal masses present. The October 2000 VA gastrointestinal examination report noted scars of the abdomen. The veteran's diastasis recti disability is rated, by analogy, under 38 C.F.R. §4.114, Diagnostic Code 7339, which provides the guidelines for rating a postoperative ventral hernia, as such postoperative residuals affects the diastasis recti muscles. A 20 percent disability rating is for application when the defect is small, not well supported by belt under ordinary conditions, or a healed ventral hernia or post-operative wounds with weakening of abdominal wall and indication for a supporting belt. A noncompensable disability rating is appropriate for healed, postoperative wounds that result in no disability and where no belt is indicated. Upon review of the evidence of record and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the veteran's claim for a compensable disability rating for his diastasis recti. This conclusion is based on the circumstances of this case, which show a healed postoperative surgical wound of the abdomen that does not require a belt and is essentially asymptomatic for any abdominal weakness. Alternatively, the Board has considered the application of 38 C.F.R. § 4.118, Diagnostic Codes 7803 and 7804, as the veteran manifests surgical skin scars on the abdomen associated with his diastasis recti. The Board notes, however, that as the scars are not shown to be poorly nourished, ulcerated, tender, or painful, these diagnostic codes do not provide for a compensable rating. In sum, as the veteran's diastasis recti is essentially asymptomatic, the preponderance of the evidence is against the veteran's claim for a compensable rating. The schedular criteria for a compensable disability rating for diastasis recti have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.14, 4.110-4.113, 4.114, Diagnostic Code 7339. Post-traumatic Stress Disorder Service connection for post-traumatic stress disorder was granted in a December 1995 rating decision, and assigned a 30 percent disability rating, which has remained in effect ever since. An October 1999 rating decision established service connection for generalized anxiety disorder and included it with the 30 percent rating for post-traumatic stress disorder. In his variously dated written statements, the veteran claims that the symptomatology associated with his post-traumatic stress disorder entitles him to a disability rating in excess of 30 percent, and that he should be separately rated for generalized anxiety disorder. An August 1999 VA psychiatric examination report includes a review of the relevant medical history. Subjectively, most of the veteran's complaints were related to his stomach problems, but he also reported continuing difficulty with sleep disturbance and nightmares triggered by flashbacks from memories of the war. The veteran further complained of being stressed out. Objectively, the veteran maintained good eye contact and spoke clearly and fluently with organized thoughts and without any indication of abnormal thought process or communication. There was no indication of abnormal impulses, panic, or obsessive or ritualistic behavior. He was oriented times four and had adequate recall of remote events, although more recent memory was not as good. Hallucinations and delusions were denied. His mood was described as "quite low" and he seemed to be depressed. Insight and judgment were intact. The diagnoses included the following: post-traumatic stress disorder, mild to moderate, prolonged; generalized anxiety disorder, secondary to post- traumatic stress disorder; and a Global Assessment of Functioning Scale score (GAF) of 70, currently and in the past year. The veteran was seen on a VA outpatient basis in July 2000 with a chief complaint of depression. The veteran was noted to be complaining of depression but no suicidal ideation. He had no other complaints. The resulting diagnoses were constipation and gastroesophageal reflux. There are no other records of the complaint, treatment or diagnoses of a psychiatric disorder in the claims file. The veteran's post-traumatic stress disorder is rated under 38 C.F.R. § 4.130, Diagnostic Codes 9411, 9440, which provide that a 50 percent disability rating is for assignment for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in 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. A 30 percent disability rating is for assignment when there is 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). With regard to the veteran's claim of entitlement to a separate rating for generalized anxiety disorder, the Board notes that generally, except as otherwise provided in the rating schedule, all disabilities, including those arising from a single entity, are to be rated separately, and then all ratings are to be combined pursuant to 38 C.F.R. § 4.25. One exception to this general rule, however, is the anti- pyramiding provision of 38 C.F.R. § 4.14, which states that evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. In Esteban v. Brown, 6 Vet. App. 259 (1994), the Court held that the disability in that case - scarring - warranted 10 percent evaluations under three separate diagnostic codes, none of which provided that a veteran may not be rated separately for the described conditions. Therefore, the conditions were to be rated separately under 38 C.F.R. § 4.25 unless they constituted the "same disability" or the "same manifestation" under 38 C.F.R. § 4.14. Esteban, at 261. The critical element cited was "that none of the symptomatology for any one of those three conditions [was] duplicative of or overlapping with the symptomatology of the other two conditions." Id., at 262. In this case, 38 C.F.R. § 4.130 provides that post-traumatic stress disorder and generalized anxiety disorder are both anxiety disorders, and both are to be rated under the same schedular criteria of Diagnostic Code 9441. Thus, as the symptomatology of both of these anxiety disorders are duplicative or overlapping, separate ratings for each would be "pyramiding", which is prohibited by 38 C.F.R. § 4.14. After a review of the relevant medical evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the veteran's claim for a disability rating in excess of 30 percent. Although the medical record reveals that the veteran experiences symptoms of sleep disturbance, nightmares, flashbacks, depressed mood, and mild memory loss of recent events, he was otherwise observed to communicate and interact normally and appropriately, without disturbance of thought process or displays of abnormal behavior. Moreover there is no evidence of record showing that the veteran has been hospitalized for his psychiatric illness or that he has undergone any sort of psychotherapy. The veteran's post-traumatic stress disorder has been characterized as mild to moderate, with a GAF of 70. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (hereinafter "DSM-IV"), a GAF of 61-70 indicates "[s]ome mild symptoms (e.g. depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within household), but generally functioning pretty well, has some meaningful interpersonal relationships." In the Board's judgment, the veteran's symptomatology more closely approximates the current 30 percent rating. As such, the assignment of the next higher 50 percent rating is not warranted. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Codes 9411, 9440. ORDER Entitlement to an increased disability rating for the residuals of post-gastric resection, with gastric reflux, currently rated as 20 percent disabling, is denied. Entitlement to an increased disability rating for diastasis recti, currently rated as noncompensable, is denied. Entitlement to an increased disability rating for post- traumatic stress disorder, currently rated as 30 percent disabling, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.