Citation Nr: 0813649 Decision Date: 04/24/08 Archive Date: 05/01/08 DOCKET NO. 06-10 843 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to an initial disability rating higher than 70 percent for psychiatric disability from February 7, 1992, through May 3, 1992. 2. Entitlement to an initial disability rating higher than 30 percent for psychiatric disability from November 1, 1992, through September 22, 2000. 3. Entitlement to an initial disability rating higher than 70 percent for psychiatric disability from September 23, 2000, through July 12, 2004. 4. Entitlement to an initial disability rating higher than 20 percent for residuals of a gunshot wound to the chest. 5. Entitlement to special monthly compensation (SMC) based on the need of regular aid and attendance. REPRESENTATION Appellant represented by: Peter J. Sebekos, attorney ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The veteran served on active duty from September 1952 to June 1954. This case comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. A motion to advance this case on the docket was granted by the Board in July 2006. See 38 U.S.C.A. § 7107(a) (West 2002); 38 C.F.R. § 20.900(c) (2007). This matter was previously before the Board, and adjudicated in a decision dated in September 2006. In that decision, the Board granted a 20 percent rating (increased from 10 percent) for residuals of a gunshot wound to the chest, granted a 70 percent rating for psychiatric disability from February 7, 1992, through May 3, 1992, and from September 23, 2000 through July 12, 2004 (increased from 30 percent), and granted a 100 percent rating for psychiatric disability from July 13, 2004 (increased from 30 percent). The Board also denied a rating higher than 30 percent for psychiatric disability from November 1, 1992, through September 22, 2000. The veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in June 2007, the Court vacated the Board decision to the extent that it denied a rating in excess of 70% for a psychiatric disability from February 7, 1992, through May 3, 1992, and from September 23, 2000, through July 12, 2004, and a rating in excess of 20 % for residuals of a gunshot wound to the chest from May 4, 1992. Those issues were remanded to the Board for action consistent with the Court's Order. The appeal as to all other issues was dismissed by the Court. In September 2007, the Board remanded the issues included in the Court's June 2007 Order for additional evidentiary development. In November 2007, the Court amended its June 2007 Order, nunc pro tunc, to include in its prior Remand that portion of the Board's September 2006 decision which denied a rating higher than 30 percent for psychiatric disability from November 1, 1992, through September 22, 2000. FINDINGS OF FACT 1. From February 7, 1992, through May 3, 1992, the social and industrial impairment from the psychiatric disability most nearly approximated severe. 2. From November 1, 1992, through November 7, 1996, the social and industrial impairment from the psychiatric disability most nearly approximated definite. 3. From November 8, 1996, through September 22, 2000, the veteran's psychiatric disability was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. From September 23, 2000, through July 12, 2004, the veteran's psychiatric disability was manifested by occupational and social impairment, which most nearly approximated deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 5. The veteran's residuals of a gunshot wound to the chest are manifested by retained metallic fragments in the left lung. 6. The veteran's service connected disabilities have resulted in physical and mental incapacity, which requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. CONCLUSIONS OF LAW 1. From February 7, 1992, through May 3, 1992, the criteria for a disability rating higher than 70 percent for a psychiatric disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996); 38 C.F.R. § 4.7 (2007). 2. From November 1, 1992, through September 22, 2000, the criteria for a disability rating higher than 30 percent for a psychiatric disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9400 (2007); 3.From September 23, 2000, through July 12, 2004, the criteria for a disability rating higher than 70 percent for a psychiatric disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9400 (2007); 4. The criteria for a disability rating higher than 20 percent for residuals of a gunshot wound to the chest are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.97, Diagnostic Code 6845 (2007); 38 C.F.R. §§ 4.7, 4.73, Diagnostic Code 5321 (2007). 5. The criteria for SMC based on the need of regular aid and attendance are met. 38 U.S.C.A. § 1114 (l) (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.350, 3.352 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran is seeking increased initial disability ratings for his service-connected psychiatric/mental disability, and for residuals of a gunshot wound to the chest. The veteran is also seeking SMC based on the need of regular aid and attendance. The Board will initially discuss certain preliminary matters, and will then address the pertinent law and regulations and their application to the facts and evidence. The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2007), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2007), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require 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. In addition, VA must also request that the veteran provide any evidence in the claimant's possession that pertains to the claim. The Board also notes that the Court has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Court further held that VA failed to demonstrate that, "lack of such a pre-AOJ-decision notice was not prejudicial to the appellant, see 38 U.S.C. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that "[i]n making the determinations under [section 7261(a)], the Court shall . . . take due account of the rule of prejudicial error")." Id. at 121. However, the Court also stated that the failure to provide such notice in connection with adjudications prior to the enactment of the VCAA was not error and that in such cases, the claimant is entitled to "VCAA-content complying notice and proper subsequent VA process." Id. at 120. The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The veteran's service connection claims were received in June 1992 and initially adjudicated in March 1996, long before the enactment of the VCAA in November 2000. The originating agency provided the appellant with the notice required under the VCAA, including notice that he should submit any pertinent evidence in his possession, by letters mailed in August 2001 and June 2005. In addition, notice concerning the effective-date elements of the claims was provided by letter mailed in August 2006. The notice required for the SMC claim was provided in March 2007. Following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the veteran's claims in March 2008. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of any claim would have been different had VCAA notice been provided at an earlier time. The Board also notes that service medical records and pertinent VA medical records have been obtained. The appellant has also submitted numerous private medical records. Neither the appellant nor his representative has identified any outstanding evidence, to include medical records, that might be pertinent to the claims. The Board is also unaware of any such outstanding evidence. In response to the Board's September 2007 Remand, two medical opinions were obtained. As will be discussed in more detail below, both reviewing physicians addressed the questions posed on remand. While the January 2008 opinion was ultimately inconclusive, the physician stated that the requested opinion could not be provided without resorting to speculation. He did not suggest that additional examination, testing or other evidence would be of assistance. The Board therefore finds that its remand instructions have been fulfilled to the extent possible, and a decision may now be reached. As noted in the Introduction, in November 2007, the Court amended its June 2007 Order. The Board finds that no additional evidentiary development is necessary to comply with the amended Order, and this also appears to be the opinion of the veteran's attorney, as stated in a December 2007 letter. In sum, the Board is satisfied that the RO properly processed the claims following the provision of the required notice and that any procedural errors in its development and consideration of the claims were insignificant and non prejudicial to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Accordingly, the Board will address the merits of the claims. Legal Criteria Disability Ratings Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2007). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2007). 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 (2007). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2007). Schedular Criteria for Mental Disorders Under the former schedule, generalized anxiety disorder warrants a 100 rating if the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community; there are totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such a fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior; or if the disorder results in a demonstrable inability to maintain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996). A 70 percent rating is assigned if the ability to establish and maintain effective or favorable relationships with people is severely impaired, and the psychoneurotic symptoms are of such severity and persistence as to result in severe impairment in the ability to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996). A 50 percent evaluation is assigned if the ability to establish or maintain effective or favorable relationships with people is considerably impaired, and by reason of psychoneurotic symptoms, the reliability, flexibility, and efficiency levels are so reduced as to result in considerable industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996). A 30 percent rating is warranted if the disorder results in definite impairment in the ability to establish or maintain effective and wholesome relationships with people and the psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996). A 10 percent rating is warranted when the manifestations of the disability are less than those required for a 30 percent rating but there is emotional tension or other evidence of anxiety productive of mild social and industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996). VA has interpreted "definite" to mean "distinct, unambiguous, and moderately large in degree." VAOPGCPREC 9- 93 (Nov. 9, 1993). The severity of disability is based upon actual symptomatology, as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful employment and decrease in work efficiency. The emotionally sick veteran with a good work record is not to be under evaluated, nor is a veteran to be over-evaluated on the basis of a poor work record not supported by the psychiatric disability picture. It is for this reason that great emphasis is placed upon the full report of the examiner, descriptive of actual symptomatology. The record of the history and complaints is only preliminary to the examination. The objective findings and the examiner's analysis of the symptomatology are the essentials. 38 C.F.R. § 4.130 (1996). Under the current schedule, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9400 (2007). A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9400. A 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9400. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9400. A 10 percent rating is warranted for generalized anxiety disorder if there is 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 where the symptoms are controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9400. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, 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 (2007). Special Monthly Compensation Special monthly compensation is payable at a specified rate if the veteran, as the result of service-connected disability, is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C.A. § 1114(l) (West 2002), 38 C.F.R. § 3.350(b) (2007). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. "Bedridden" will be a proper basis for the determination. A veteran will be found to be bedridden if the condition actually requires that he remain in bed, but not if he voluntarily stays in bed or if a physician merely recommends bed rest. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. Burdon of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis Psychiatric/Mental Disability (i.) Preliminary Matters As discussed in the Introduction, in June 2007, the Court vacated those portions of the Board's September 2006 decision which denied entitlement to an initial rating for psychiatric/mental impairment in excess of 70 percent from February 7, 1992, through May 3, 1992, and from September 23, 2000 through July 12, 2004, as well as entitlement to an initial rating in excess of 30 percent from November 1, 1992, through September 22, 2000. The reasons for the Court's remand, as stipulated in a joint motion of the parties, were that the Board failed to consider records indicating that the veteran was entitled to VA aid and attendance benefits, along with special monthly pension at the housebound rate, and that he had been rated 100 percent disabled for pension purposes, due to major depression, with history of a fracture of the skull, vertigo, headaches, and panic attacks. The Board also did not address the RO's October 1994 statement that, due to the severity of the veteran's nervous condition, he cannot be left alone. In addition, the Board did not discuss a June 1994 medical statement in support of the claim for aid and attendance benefits indicating that the veteran has severe panic attacks when left alone and he is unable to care for himself in any way due to mental instability and physical ailments. These reasons all pertain to the period from November 1, 1992, through September 22, 2000, in which a 30 percent rating is currently assigned, and they will be addressed in conjunction with that discussion. It is now well-settled law that a remand by the Court is not merely for the purpose of rewriting an opinion so that it will superficially comply with the requirements to provide a comprehensive statement of the reasons or bases for its decision. See Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991). The Board's analysis has been undertaken with that directive in mind. As a result of the Board's September 2006 decision, the veteran is currently assigned a 70 percent disability rating from February 7, 1992, through May 3, 1992, and from September 23, 2000, through July 12, 2004. He is currently assigned a 30 percent rating from November 1, 1992, through September 22, 2000. He is seeking a 100 percent rating for those periods. Although the veteran has multiple psychiatric/mental diagnoses, with the exception of eating disorders, all mental disorders, including PTSD, major depressive disorder and anxiety disorders, are rated under the same criteria in the rating schedule, which are set out above. As the diagnosed disorders in this case are manifested by similar symptomatology, separate disability ratings cannot be assigned without violating the general prohibition against pyramiding. See 38 C.F.R. § 4.14 (2007). During the pendency of this claim, the criteria for evaluating psychiatric disorders were revised, effective November 7, 1996. In VAOPGCPREC 7- 2003, the General Counsel held that when a new statute is enacted or a new regulation is issued while a claim is pending before VA, VA must first determine whether the statute or regulation identifies the types of claims to which it applies. If the statute or regulation is silent, VA must determine whether applying the new provision to claims that were pending when it took effect would produce genuinely retroactive effects. If applying the new provision would produce such retroactive effects, VA ordinarily should not apply the new provision to the claim. If applying the new provision would not produce retroactive effects, VA ordinarily must apply the new provision from their effective date. VAOPGCPREC 7-2003. In accordance with VAOPGCPREC 7-2003, the Board has reviewed the revised rating criteria. The revised rating criteria would not produce retroactive effects since the revised provisions affect only entitlement to prospective benefits. Therefore, VA must apply the new provisions from their effective date. The Board also notes that the grant of service connection in October 2003 was based on aggravation of a pre-existing psychiatric/mental disability due to VA treatment in March 1990 under 38 U.S.C. § 1151. While the veteran's psychiatric/mental disability did not predate service, it did predate the VA treatment that provided the basis for service connection. The Court has held that, when aggravation of a non-service- connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See Allen v. Brown, 7 Vet. App. 439, 448. See also 38 C.F.R. §§ 3.310, 3.322 (2007). Although the cited regulations are nominally applicable to preservice disabilities, the Court in Allen found the provisions of 38 C.F.R. § 3.322 also applicable to aggravation of non-service-connected conditions by service- connected conditions. That section provides that, it is necessary to deduct from the present evaluation the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule. As applied by the Court in Allen, the Board interprets this language as requiring deduction from the present evaluation, the degree of disability existing prior to the aggravation. As alluded to above, a medical opinion was obtained on remand to assist the Board in determining the appropriate amount of this deduction. However, the January 2008 opinion was ultimately inconclusive, the physician stated that the requested opinion could not be stated with any certainty without resorting to speculation. Although VA may compensate the veteran only for service- connected disability, the Board is precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Here, the evidence does not adequately distinguish between service-connected and non-service-connected mental diagnoses with respect to the resulting symptomatology. Accordingly, consistent with the holding in Mittleider; and, as found in the Board's September 2006 decision, the Board must consider those symptoms as part of the service-connected disorder. (ii.) 70 Percent Ratings The Board previously found that a 70 percent rating is warranted from February 7, 1992, through May 3, 1992, and from September 23, 2000, through July 12, 2004. That portion of the decision has been affirmed by the Court. Upon review of the evidence, the Board finds here that a higher 100 percent rating is not in order for either period. A February 2004 report from L.S., M.D. shows that the veteran was experiencing worsening depression, confusion and agitation, and that he was "significantly depressed." On September 23, 2000, an MMPI-2 was administered, showing that the veteran had multiple mental/emotion-based problems with few coping resources. The examiner noted that the veteran tended to present multiple dramatic somatic concerns that were suggestive of a loss of reality contact at times. His responses suggested that he was in great turmoil, feeling both depressed and quite panicked. The Board notes however that near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, are criteria for the 70 percent level. The fact that the veteran has panic attacks does not suggest entitlement to a 100 percent rating. The September 2000 examiner noted that the veteran had no plans for the future beyond the moment, and was constantly anticipating his own death. The veteran also had heightened irritability as compared to pre-trauma levels. A February 2004 psychiatric evaluation report shows that the veteran thinks of death frequently, but denied any plans or intention to harm himself or others. Psychiatric outpatient notes in January 2002 and May 2002 show no suicidal ideas or plans. The Board notes that suicidal ideation is a criterion for the 70 percent level. While the veteran clearly has a history of a suicide attempt, the evidence during this period does not suggest that the veteran went beyond ideation such that he was in persistent danger of hurting himself or others. There is no suggestion from the evidence during this period that the veteran was intermittently unable to perform activities of daily living (including maintenance of minimal personal hygiene), that he was disoriented to time or place, or that he had memory loss for names of close relatives, his own occupation or his own name. The evidence is not consistent with persistent delusions or hallucinations, or grossly inappropriate behavior. Moreover, findings in September 2000 show a marked inability to make decisions, but not total incapacity or gross impairment in thought processes, as reflective of a 100 percent evaluation. The September 2000 examiner noted that the veteran had withdrawn from activities and tried to avoid emotions and thoughts related to his suicide attempt. He was found to have a morbid fear of being alone. He felt no closeness of any sort with anyone except his wife, due to feelings of being different from others due to his past suicide attempt. However, the criteria for the 100 percent level appear to require more than social withdrawal, but total occupational and social impairment. Although the veteran's ability to relate socially is clearly quite limited, it does not appear to be totally impaired. The Board notes in particular that the veteran's Global Assessment of Functioning (GAF) score of 52, as assigned in September 2000, is not consistent with total impairment of social or industrial functioning, but is consistent with moderate impairment of social and industrial functioning. A GAF score of 52 falls within the range of generally 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). Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 50 was assigned in January 2001 which reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. However, such serious impairment in functioning is more consistent with the criteria enumerated above for a 70 percent rating than with total impairment as required for a 100 percent rating. These GAF scores appear to be based on the veteran's reported symptomatology. There have been assigned no lower GAF scores during this period, and the evidence does not indicate behavior or impairment in functioning consistent with lower GAF scores. During the period from February 7, 1992, through May 3, 1992, just prior to the assignment of a total rating, a February 7, 1992, hospital discharge summary indicates that the veteran had a severe anxiety disorder. On examination, he was found to be extremely anxious. The veteran was hospitalized in March 1992 due to lower abdominal pain, and stated that he planned to overdose on pills to make the pain go away. The veteran was discharged without further reference to suicidal ideation or plan. A GAF score of 65 was assigned during a hospitalization in March 1992, reflecting essentially mild symptoms. Id. Based on such evidence, the Board finds no indication during this period that there were totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such a fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior, as required for a 100 percent rating under the former criteria. The GAF score of 65 clearly does not support symptomatology of such severity, and the finding of extreme or severe anxiety falls far short of total incapacitation. Moreover, the evidence for this period does not demonstrate that the attitudes of all contacts except the most intimate have been so adversely affected as to result in virtual isolation in the community. The Board notes again that this implies more than just social withdrawal on the veteran's part, or the constrained social circle that the veteran appears to have, but clearly refers to the attitudes of others, and therefore contemplates a situation where, due to the veteran's behavior and psychiatric symptomatology, others refrain from interaction with him. This is not shown in the evidence or even alleged. The veteran has been unemployed since 1975, and it may fairly be conceded that, due to the combined effect of service- connected and non-service-connected disabilities, he has been unemployable during that period. However, the evidence for the period prior to July 13, 2004, does not establish that he was demonstrably unable to obtain or retain employment due to his service-connected psychiatric symptomatology. The record contains letters from H.G.P, a licensed psychologist, and L.A.Y., D.O., both dated in October 2001, which basically attest to the veteran's total occupational impairment. However, these opinions are based on all of the veteran's disabilities, physical and mental, service-connected and non- service-connected. The evidence discussed above, and the GAF scores assigned do not demonstrate that the veteran was unable to obtain or retain employment due exclusively to his service-connected psychiatric/mental symptomatology. As the record contains findings and GAF scores specific to the service-connected disability, the Board assigns higher probative weight to such evidence, than to evidence which does not distinguish between service-connected and non- service-connected disabilities. This is entirely consistent with Mittleider, 11 Vet. App. at 182. Accordingly, based on consideration of both versions of the rating schedule, the Board concludes that a 100 percent rating is not warranted from February 7, 1992, through May 3, 1992, or from September 23, 2000 to July 18, 2004, because the service-connected symptomatology did not more nearly approximate the criteria for a 100 percent rating during either period. (iii.) 30 Percent Rating The veteran is currently assigned a 30 percent rating from November 1, 1992, through September 22, 2000. The criteria for a rating higher than 30 percent are set out above. For reasons that will now be discussed, the Board finds that a rating higher than 30 percent is not warranted. While disability ratings of 70 percent and 100 percent were assigned prior to November 1, 1992, the Board finds that the symptomatology demonstrated during this period represents a genuine improvement in the severity of the veteran's psychiatric/mental disability. The Board notes as particularly significant, a November 1992 mental hygiene note stating that the veteran's depression has decreased to a low level. There is no evidence of disorder in form or content of thoughts. There is no report of hallucinations. Judgement is adequate to meet daily needs. Insight is good. Along the same lines, the report of a December 1997 VA psychiatric consultation shows that the veteran's depression was found to be stable. GAF scores of 75 were assigned in July 1999 April 1999, and January 1999, indicating transient symptoms and no more than slight impairment in social, occupational, or school functioning. Richard v. Brown, supra. With respect to the rating criteria under the current rating schedule, the Board finds that the evidence is not consistent with a flattened affect. A March 1994 VA neuropyschiatric examination showed that the veteran's affect was appropriate. An August 1994 mental hygiene note also shows that the veteran's affect was appropriate. In August 1993, the veteran was found to have no affective disorder. In October and November 1993, while there was some restriction of affect, it was not found to be flattened. The evidence is not consistent with difficulty in understanding complex commands. A March 1994 VA neuropyschiatric examination showed that the veteran's insight, judgment and intellectual capacity were adequate. The veteran was alert and cooperative with no loose associations or flight of ideas. The evidence is not consistent with impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks). A March 1994 VA neuropyschiatric examination showed good remote and recent memory. A March 1995 VA examination showed that the veteran's memory was adequate. The evidence is not consistent with impaired judgment. A March 1994 VA neuropyschiatric examination showed judgment to be adequate. An August 1994 mental hygiene note shows that judgment was adequate to meet daily needs and there was a good contact with reality. In August 1993, the veteran was found to have a realistic attitude. In November 1993, the veteran's judgment appeared adequate to meet daily needs. In November 1993, the veteran was found to have good thought form and content. In October 1993, the veteran showed no disordered judgment. A March 1995 VA examination showed that insight and judgment were adequate. A July 1999 progress note shows that the veteran's thoughts were logical and non delusional. Similar results were reported in April 1999 and January 1999. The evidence is not consistent with disturbances of motivation and mood. In a December 1995 evaluation, the examiner made note of "death - lying in casket at funeral home - shot at by enemy." It is unclear what significance this notation had. However, a March 1994 VA neuropyschiatric examination showed no suicidal or homicidal ideation. An August 1994 mental hygiene note showed that the veteran's mood was good. There was no suicidal or homicidal ideation. In August 1993, the veteran was found to have normal mood fluctuations, and no suicidality. The report of a December 1997 VA psychiatric consultation shows that the veteran appeared pleasant and was cracking jokes. In November 1993, while the veteran was found to still have depressive symptoms, there were no ruminations, no suicidality and no homicidality. A July 1999 progress note shows that the veteran had no suicidal or homicidal ideation. Similar results were reported in April 1999 and January 1999. The evidence is not consistent with circumstantial, circumlocutory, or stereotyped speech, or impaired abstract thinking. There are no pertinent findings with respect to the second criterion. A March 1995 VA examination showed that verbal productivity was adequate. The report of a December 1997 VA psychiatric consultation shows that the veteran had clear speech. The evidence is not consistent with panic attacks more than once a week. The veteran has been noted to demonstrate anxiety during this period, as well as panic attacks. In particular, in October 1993, it was noted that the veteran's symptoms were suggestive of anxiety with a marked concentration deficit. A June 1994 medical statement in support of the claim for aid and attendance benefits notes that the veteran has severe panic attacks when left alone. However, the Board notes that panic attacks (weekly or less often) are one of the criteria for the current 30 percent level. There is no indication that the veteran suffers symptoms of the type and degree contemplated for a 50 percent rating. In essence, the evidence during the period from November 1, 1992, through September 22, 2000, shows essentially mild to moderate symptoms which do not demonstrate the type or degree of symptoms required for a rating higher than 30 percent. The Board acknowledges that an October 1993 VA outpatient treatment report shows that the veteran had a very dependent demeanor rendering him excessively dependent on his wife and therapist, and that he became depressed when his wife attended to other activities, and became agitated and anxious with marked concentration deficit. In addition, a March 1995 VA examination showed that the veteran had few regular activities except church. This evidence is pertinent to the current criterion of difficulty in establishing and maintaining effective work and social relationships, and to the former criteria of considerable impairment in the ability to establish or maintain effective or favorable relationships with people, and considerable industrial impairment by reason of psychoneurotic symptoms resulting from reduction of reliability, flexibility, and efficiency levels. In the Board's view, the veteran's social impairment is the strongest evidence in favor of a higher rating. However, in light of the veteran's serious overall disability picture, including service-connected and non-service-connected physical and mental disabilities, there is no indication that a dependent demeanor even represents psychiatric symptomatology. The noted anxiety when the veteran's wife is not present has been discussed above, and is not a basis for a rating higher than 30 percent. In this instance, the Board is inclined to favor evidence such as GAF scores, which more clearly describe the level of overall mental function. The Board concludes that, these findings alone, or in connection with the other evidence during this period, do not suggest that the veteran suffered considerable industrial and social impairment due to psychiatric/mental symptomatology. The joint motion stipulates that the Board in its prior decision did not address an October 1994 statement by the RO that, due to the severity of the veteran's nervous condition, he cannot be left alone. In addition, the Board did not discuss a June 1994 medical statement in support of the claim for aid and attendance benefits indicating that the veteran has severe panic attacks when left alone and he is unable to care for himself in any way due to mental instability and physical ailments. These were found to be significant because the veteran was rated totally disabled due to psychiatric illness, for purposes of non-service-connected pension, prior to the adjudication which established entitlement to service connection for a psychiatric disorder. With respect to the first reference, the October 1994 RO rating decision includes the following discussion: Prior rating action had discontinued aid and attendance benefits effective May 1, 1993. Additional evidence has been received and reviewed. The additional evidence shows the veteran continues to have significant disabilities including nervous condition, lung condition, orthopedic disabilities and glaucoma. He has severe anxiety, shortness of breath and panic attacks. He has significant restriction of visual fields. The veteran requires assistance with dressing, bathing and shaving. He is not able to protect himself from the hazards and dangers of his daily environment. Due to the severity of his nervous condition he cannot be left alone. The June 1994 medical statement for consideration for aid and attendance, shows diagnoses of COPD, bronchitis, coronary artery disease, costochondritis, hiatal hernia with gastroesophageal reflux, diverticulosis, degenerative arthritis of the lumbar spine with spinal stenosis, and psychiatric diagnosis of major depression with suicide attempts and panic attacks. The examiner noted that the veteran has severe panic attacks when left alone and is unable to care for himself in any way due to his mental instability and physical ailments. With respect to both statements, the Board finds them of less probative significance than the evidence discussed above. Both the October 1994 rating decision and the June 1994 statement, while they contain pertinent findings with respect to the veteran's psychiatric/mental disorder, ultimately relate to his combined service-connected and non-service- connected disabilities. While the June 1994 examiner reported severe panic attacks, this fact has already been discussed in detail. Panic attacks are a criterion for a 30 percent rating. The statement that he is unable to care for himself in any way due to mental instability and physical ailments combines service-connected and non-service-connected disabilities, and provides no basis upon which to evaluate the respective roles of those disabilities. It is conceded that the veteran has multiple disabilities. In this discussion, it is the task of the Board to evaluate but one of those disabilities. In the presence of evidence which purports to distinguish the veteran's psychiatric symptomatology from physical symptomatology, the Board assigns greater probative weight to such evidence in comparisons to the June 1994 report. This is entirely consistent with Mittleider, 11 Vet. App. at 182. With respect to the October 1994 rating decision, the Board notes that it is not bound by the findings of the RO. The RO's decision relates to a determination of entitlement to aid and attendance benefits for pension purposes. All service-connected and non-service connected disabilities were considered. The RO's finding that, due to the severity of his nervous condition he cannot be left alone, is the operative finding in terms of the issue on appeal. This appears to relate to a March 1994 VA aid and attendance examination, which reported that the veteran is not able to protect himself from hazards and dangers of daily environment. He suffers from shortness of breath with minimal exertion, and severe panic disorder. His wife is not able to work as the veteran constantly needs his wife to be around. He gets really frightful by himself with hallucinations. However, this report contrasts sharply with the purely psychiatric clinical evidence during the same period. Indeed, a March 1994 VA neuropyschiatric consultation, conducted on the same day as the aid and attendance examination, but by a different physician, showed the veteran to be alert and cooperative with no loose associations or flight of ideas. There were no bizarre motor movements or tics. Affect was appropriate. There were no delusions, hallucinations, ideas of reference or suspiciousness. There was no suicidal or homicidal ideation. The veteran was oriented with good remote and recent memory. Insight, judgment and intellectual capacity were found to be adequate. Similarly, in December 1992, there was no psychosis, and indeed, the veteran was found to have good coping skills. Arthritis was considered to be his primary problem. An August 1994 mental hygiene note shows that the veteran had a good mood and appropriate affect. He was in good contact with reality. His judgement was found adequate to meet daily needs. There was no suicidal or homicidal ideation. In light of the purpose of the March 1994 aid and attendance examination, which was to evaluate the veteran's overall ability to care for himself, and not to specifically evaluate his mental condition, the Board assigns greater probative weight to the report of the VA neuropsychiatric examination and other clinical evidence during this period than to the report of the aid and attendance examination for pension purposes, or the findings of the RO with respect to aid and attendance and pension. Accordingly, based on consideration of both versions of the rating schedule, the Board concludes that a rating higher than 30 percent is not warranted during the period from November 1, 1992, through September 22, 2000, because the disability did not more nearly approximate the criteria for a 50 percent rating during that period. (iv.) Specific Contentions The Board notes, as discussed in the June 2007 joint motion, that the veteran was rated totally disabled due to psychiatric illness, for purposes of non-service-connected pension, prior to the adjudication which established entitlement to service connection for a psychiatric disorder, effective from February 1992. The veteran's attorney essentially contends that this rating should be carried over as the service-connected rating, and that any reduction in the percentage assigned for pension purposes should be treated as a rating reduction. The Board again points out that this case involves the initial disability rating assigned following the grant of service connection. The Court has established the concept of the "staging" of ratings in such cases, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson v. West, 12 Vet. App. 119 (1999). The Court's holding was recently expanded to all increased rating claims in Hart v. Mansfield, 21 Vet. App. 505 (2007). The concept explicitly recognized in these cases is that disabilities may change in severity over time, and it is entirely appropriate for the assigned disability rating to reflect those changes. The Board has considered the regulatory provisions pertaining to stabilization of disability evaluations, continuance of total disability ratings, and preservation of disability ratings, see 38 C.F.R. §§ 3.343, 3.344, 3.951 (2007). However, those provisions appear under the heading "Ratings and Evaluations; Service Connection." They do not apply to ratings assigned for pension purposes, which are found under a separate heading, and which do not include like provisions. Similarly, there are several general VA regulations which the Court has found applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. See 38 C.F.R. §§4,1, 4.2, 4.10 (2007). However, as stated above, this case does not involve a rating reduction. It involves the assignment of staged initial disability ratings in conjunction with the grant of service connection. The Board does not believe that the existence of a pension rating or the amount thereof, to include a finding of entitlement to aid and attendance for special monthly pension purposes, are controlling factors in the assignment of a disability rating for service-connected disability. Controlling law and regulations provide that the establishment of a disability rating should be based on all of the evidence of record. To find otherwise would be to afford preferred status, and indeed a protected rating, to veterans who received a pension prior to a grant of service connection for the same disability. Such status and such protection are not specifically provided in VA law. In the Board's view, the only appropriate basis for the veteran's disability rating during any particular period on appeal can be the evidence of record reflecting his actual symptomatology during that period. The veteran's attorney has also asserted that many if not all of the psychiatric assessments cited by the Board in support of a rating less than 100 percent were made when the veteran's wife accompanied him to his mental health clinic appointments. Due to the veteran's profound dependence on his wife for stability and psychological support, the Board should view these assessments with a degree of skepticism. The attorney posited that, to fairly weigh the evidence, the Board should seriously consider whether the veteran's psychiatric disorder would have manifested itself in a far more debilitating manner, without the reassuring presence and support of his wife. In essence, the veteran's attorney invites the Board to speculate on a hypothetical situation. This the Board cannot do. It is presumed that the psychiatric and medical examiners who have evaluated the veteran and in fact reported the veteran's dependence on his wife, are competent to distinguish the effect of such symptomatology on his clinical presentation. The Board does not possess this particular competence, and must base its decision on the evidence reported. Gunshot Wound Residuals The Board notes initially that this matter was remanded by the Court so that the Board could ensure that the veteran was provided with a medical opinion to address the question of "whether non-service COPD related to emphysema, the service- connected gunshot wound residuals, or a combination of the two, caused Appellant's current decrease in lung volume." On remand to the originating agency, a medical opinion was requested. The examiner was asked to summarize the extent and manifestations of the service-connected gunshot wound residuals, to describe those symptoms that are attributable to the gunshot wound residuals, as opposed to those that are attributable to non-service-connected pathology, and to state whether, and if so to what extent, the non-service-connected COPD, the service-connected gunshot wound residuals, or a combination of the two, caused the current decrease in lung volume. A medical opinion was obtained in December 2007. The veteran was originally assigned a 10 percent rating for gunshot wound residuals of the chest under Diagnostic Code 5321, which governs injuries to Muscle Group XXI. Noting that X-rays in May 1992 and February 2002 showed metallic fragments retained in the left lung consistent with old projectile injury, the Board assigned an increased 20 percent initial rating on the basis of 38 C.F.R. § 4.104, Diagnostic Code 6845, which provides that a minimum rating of 20 percent will be assigned for gunshot wounds of the pleural cavity, where a bullet or missile is retained in the lung, where there is pain or discomfort on exertion, or where there are scattered rales or some limitation of excursion of the diaphragm or of lower chest expansion. Under that provision, involvement of Muscle Group XXI will not be separately rated. While ratings higher than 20 percent are available under Diagnostic Code 6845, on the basis of chronic pleural effusion or fibrosis, the Board finds that such a rating is not appropriate in the veteran's case. To warrant a 30 percent rating, the pulmonary function tests would have to show FEV-1 of 56- to 70 percent predicted; FEV-1/FVC of 56 to 70 percent; or DLCO (SB) 56- to 65-percent predicted. In this case, pulmonary function tests in July 1992 showed mild chronic obstructive pulmonary disease and emphysema. FEV-1 was noted to be 70 percent predicted. A chest X-ray in September 1988 also showed mild COPD. Moreover, the Board notes that post-injury X-ray reports show only a hematoma in the left lung with the loss of some lung tissue, but with essentially clear and normal findings for the right lung. More significantly, the veteran has been diagnosed with end-stage COPD, which is not service connected, and which predates his gunshot wound to the chest. A crucial question to be determined in connection with this appeal, therefore, is whether the veteran's non service- connected pathology is primarily responsible for any pulmonary symptomatology. In addressing this question, the December 2007 reviewing physician concluded that the continuing deterioration in pulmonary function tests is more likely due to the chronic obstructive pulmonary disease than to the sequelae of the gunshot wound. While a small percentage of the loss of lung volume may be attributed to the gunshot wound, the vast majority of the loss of lung volume and the decrease in pulmonary function and increase in hypoxia, are secondary to his chronic obstructive pulmonary disease. The VA physician noted that bronchoscopy conducted in July of 1992 revealed chronic changes of the lung tissue related to COPD, and also revealed probable fibrosis from the hemopneumothorax from the gunshot wound. The veteran was noted to have a normal bronchoscopy at the time of his evaluation. The physician stated that, since that time the veteran has had a continuation and progression of COPD, and his arterial blood gases over the past several years have deteriorated to the point where he was placed on at-home oxygen. With respect to pulmonary fibrosis, the veteran was noted to have a mild degree prior to the self-inflicted gunshot wound. While the physician acknowledged that a determination of the precise amount of fibrosis that is attributable to the gunshot wound versus that attributable to COPD is really not possible without resorting to speculation, he went on to state that, given the veteran's significant non-service- connected lung disorder, that "the vast majority" of his current decrease in lung volume and pulmonary function, and the increase in hypoxia are due to his COPD. Here, despite the physician's wording, the Board finds that his opinion is not inconclusive. The "precise amount" of fibrosis attributable to the service-connected disability was not requested and is not necessary for the Board to reach a decision. The physician's finding that the "vast majority" of the decrease in lung volume and pulmonary function was attributable to non-service-connected pathology is sufficiently conclusive without the precise amount being provided. It was the opinion of L.A.Y., D.O. in October 2001 that the chest wound has caused a "great deal of pulmonary problems." However, this opinion was not apparently based on a physical examination of the veteran. Further, it is not instructive as to the definition of "great deal." Unlike the December 2007 opinion, it does not address the relative contributions of the gunshot wound and COPD. For these reasons, the Board finds that opinion of the December 2007 VA physician to be more probative. The Board has considered the veteran's statements, and those of his attorney, evidencing their belief that the veteran's service-connected gunshot wound residuals are primarily responsible for his deterioration in pulmonary function. However, as laypersons, they are not qualified to render an opinion concerning medical causation or attribution of symptomatology. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board places significant weight on the conclusion of the December 2007 reviewing physician and on the other medical evidence of record. Such evidence demonstrates that the veteran's pulmonary impairment is mostly attributable to his non-service-connected COPD. For these reasons, the Board has concluded that a disability rating higher than 20 percent is not warranted under Diagnostic Code 6845 on the basis of chronic pleural effusion or fibrosis. The Board has also considered whether a rating higher than 20 percent is justified under any other potentially applicable diagnostic code. The Board notes that a 20 percent rating is the maximum rating available under Diagnostic Code 5321. This is true under both the current regulations and those in effect prior to the June 1997 amendments. Moreover, Note 3 under Diagnostic Code 6845 precludes assigning a separate rating under Diagnostic Code 5321 in addition to a rating under Diagnostic Code 6845. With respect to additional functional impairment due to pain, weakness, fatigue or incoordination, in Johnston v. Brown, 10 Vet. App. 80, 85 (1997), the Court determined that if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether a higher rating is warranted based on the functional impairment specified in 38 C.F.R. §§ 4.40 and 4.45 (2007). In the instant case, the veteran is assigned a 20 percent evaluation, the maximum evaluation under Diagnostic Code 5321. Accordingly, the aforementioned provisions are not for consideration. The Board has also considered whether a separate rating for the veteran's gunshot wound scars is appropriate. See Esteban v. Brown, 6 Vet. App. 259, 261(1994). However, the evidence shows that the veteran has only a small one-inch entry scar on the chest and a similar exit scar on the back. There is no evidence or assertion that these scars are painful, deep, unstable, ulcerated, poorly nourished, disfiguring, or adherent, or that they impair motion or function. Accordingly, a compensable rating for scars is not warranted under the current or former version of the rating schedule. See 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2002 & 2007). In sum, for the reasons discussed above, the Board finds that a schedular evaluation higher than 20 percent for the veteran's gunshot wound residuals is not in order for any portion of the initial evaluation period. Other Considerations The Board has considered whether this case, or any component thereof, should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. By regulation, extra-schedular ratings may be assigned where the schedular criteria are inadequate and there are exceptional factors such as the need for frequent hospitalization or marked interference with employment. 38 C.F.R. § 3.321(a) (2007). While the veteran has been hospitalized repeatedly for many reasons, the record does not reflect that the veteran has required frequent hospitalizations for his psychiatric disability or gunshot wound residuals. In addition, the record does not reflect that the manifestations of disability are in excess of those contemplated by the schedular criteria. Clearly, the veteran's service connected disorders interfere with his industrial capacity, and limit his ability to engage in employment. However, the disability ratings assigned are recognition that industrial capabilities are impaired. See Van Hoose, 4 Vet. App. at 363. The type of impairment demonstrated by the evidence of record is completely consistent with the disability ratings assigned. In sum, the record, when considered as a whole, does not indicate that the average industrial impairment from these disabilities would be in excess of that contemplated by the assigned evaluations. Accordingly, the Board has concluded that referral of this case for extra-schedular consideration is not in order. SMC-Aid and Attendance The evidence in this case, discussed in detail above, clearly establishes that the veteran suffers physical and mental incapacity which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. Although the evidence does not clearly establish that this incapacity is solely due to service-connected disability, the Board finds that an allowance is appropriate in this case. The Board distinguishes this situation from the situation presented above with respect to the initial ratings assigned for psychiatric/mental disability prior to July 2004. In particular, with respect to the period from November 1, 1992, through September 22, 2000, in which a 30 percent rating for psychiatric/mental disability is currently assigned, the Board found that, while the evidence did not distinguish service-connected mental symptomatology from non-service- connected symptomatology, there was strong evidence that allowed the Board to determine which part of the veteran's overall disability picture was attributable to psychiatric/mental impairment, as opposed to physical impairment. Here, there is no such evidence. In a November 2005 letter, the veteran's private physician, M.L.S., M.D. stated that the veteran has multiple medical problems. He is currently living in a nursing home and is unable to attend outpatient visits due to his medical conditions. In a March 2007 medical statement for consideration for aid and attendance, the veteran was found not to be able to leave home, to bathe or toilet, or to dress without the assistance of another. This was due to multiple diagnoses. In a July 2004 letter, the veteran's private physician, T.V., stated that the veteran was physically unable to manage his VA affairs and also suffers period of mental disorientations which preclude him from being able to manage his own affairs. As none of these reports differentiates between symptomatology attributed to non-service-connected disability and a service-connected disability, and as the Board has no other medical evidence which does so, the Board concludes with resolution of reasonable doubt in the veteran's favor that he does require the regular and aid and attendance of another as a result of his service-connected disabilities. Accordingly, the Board finds that SMC based on the need of regular aid and attendance is in order. (CONTINUED ON NEXT PAGE) ORDER A disability rating higher than 70 percent for psychiatric disability from February 7, 1992, through May 3, 1992, is denied. A disability rating higher than 70 percent for psychiatric disability from September 23, 2000, through July 12, 2004, is denied. A disability rating higher than 30 percent for the veteran's psychiatric disability from November 1, 1992, through September 22, 2000, is denied. A disability rating higher than 20 percent for residuals of a gunshot wound to the chest is denied. Entitlement to SMC based on the need of regular aid and attendance is granted, subject to the criteria applicable to the payment of monetary benefits. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs