Citation Nr: 1127011 Decision Date: 07/20/11 Archive Date: 07/29/11 DOCKET NO. 09-09 681 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a rating in excess of 50 percent prior to October 14, 2009, and in excess of 70 percent thereafter, for posttraumatic stress disorder (PTSD). 2. Entitlement to a compensable rating for shrapnel wounds of the right arm, right thigh and right leg, to include scarring. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from August 1969 to February 1972. This appeal to the Board of Veterans' Appeals (Board) arises from rating decisions of the Jackson, Mississippi Regional Office (RO) of the Department of Veterans' Affairs (VA). In March 2011, a Board hearing was held at the RO before the undersigned Veteran's Law Judge; a transcript of the hearing is of record. The Board is cognizant that under certain circumstances a claim for increase may also constitute a claim for a total disability rating based on individual unemployability due to service-connected disability (TDIU). However, in the instant case, a claim for a TDIU was separately adjudicated in a May 2010 rating decision and a January 2011 statement of the case after which the Veteran did not file a VA Form 9 to appeal the decision to the Board. Accordingly, the issue of entitlement to a TDIU is not currently before the Board. FINDINGS OF FACT 1. Prior to October 14, 2009, the Veteran's PTSD was manifested by depressed mood, feelings of sadness, crying spells, poor energy, decreased sleep, feelings of helplessness, hopelessness and worthlessness, sensory anomalies, flashbacks almost daily, nightmares, night sweats, avoidance of reminders of trauma, avoidance of friends that were in the war with him, social isolation, decreased interest in activities, difficulty concentrating and increased irritability. These symptoms resulted in occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas was not shown. 2. From October 14, 2009, the Veteran's PTSD has been manifested by symptoms of social isolation, indecisiveness, depression, depressed and dysphoric mood, sense of foreshortened future, feelings of worthlessness and hopelessness, suicidal ideation, difficulty feeling pleasure, sleeping problems, flashbacks, nightmares, detachment, emotional numbness, irritability, concentration and attention problems and exaggerated startle response. These symptoms have resulted in occupational and social impairment with deficiencies in most areas. Total occupational and social impairment has not been shown. 3. From November 25, 2006 to August 20, 2008, the Veteran's scars on the posteromedial aspect of the right arm, the scar along the ulnar border of the right mid forearm, the scar over the posterior aspect of the right mid thigh and the scar on the poserolateral aspect of the right thigh were found to be objectively painful on examination. These scars were not shown to be deep, to result in limitation of motion or to otherwise result in limitation of function of an affected part. 4. During the entire appeals process, the scars of the medial aspect of the elbow and the anterolateral aspect of the right leg were not found to be painful on examination and were also not found to be deep, covering an area exceeding six square inches, unstable, or to result in any limitation of motion or limitation of function of an affected part. 5. From August 20, 2008, none of the Veteran's shrapnel scars are shown to be painful on examination, covering an area in excess of 144 square inches (even when the areas of all scars are combined), unstable, or to result in any limitation of motion or function of an affected part. Although some of the scars were found to be deep, none of these scars, alone or added together, covers an area exceeding six square inches. CONCLUSIONS OF LAW 1. Prior to October 14, 2009, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. From October 14, 2009, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). 3. From November 25, 2006 to August 20, 2008, the criteria for assignment of four individual 10 percent ratings for scars on the posteromedial aspect of the right arm, along the ulnar border of the right mid forearm, over the posterior aspect of the right mid thigh and on the poserolateral aspect of the right thigh have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. § 4.118, Codes 7801, 7802, 7803, 7804, 7805 (2008); 38 C.F.R. §§ 4.7, 4.118, Codes 7801, 7802, 7804, 7805 (2010). 4. From August 20, 2008, the criteria for a compensable rating for service connected shrapnel wounds of the right arm, right thigh and right leg, to include scarring are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. § 4.118, Codes 7801, 7802, 7803, 7804, 7805 (2008); 38 C.F.R. §§ 4.7, 4.118, Codes 7801, 7802, 7804, 7805 (2010). 5. At no time during the appeal period is a compensable rating warranted for scars of the medial aspect of the elbow and the anterior aspect of the right leg. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. § 4.118, Codes 7801, 7802, 7803, 7804, 7805 (2008); 38 C.F.R. §§ 4.7, 4.118, Codes 7801, 7802, 7804, 7805 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2010)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claims, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In the present case, the Board finds that VA has satisfied its duty to notify. By way of a VCAA notice letter sent to the Veteran in September 2006, the RO generally informed the Veteran of the evidence necessary to substantiate his claims and his and VA's responsibilities in claims development. Also, the Veteran was informed that in evaluating his disability, VA would consider evidence of the nature and symptoms of his condition; the severity and duration of his symptoms; and the impact of his condition and symptoms on employment. Additionally, he was notified of the general manner in which disability ratings are assigned, and examples of the types of evidence he could submit, or ask VA to obtain, were also provided. As this notice was provided prior to the initial May 2006 rating decision, no further corrective action is necessary. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the Veteran's claim. Pertinent medical evidence associated with the claims file consists of VA treatment records, Social Security Administration (SSA) records, private treatment records and the reports of VA examinations. Also of record and considered in connection with the appeal is the transcript of the March 2011 Board hearing, along with various written statements provided by the Veteran and by his representative on his behalf. The Board notes that no further RO action, prior to appellate consideration of the claim, is required. II. Factual Background The Veteran's available service treatment records are apparently limited to an August 1969 entrance examination report, an August 1969 report of medical history and a January 1972 separation examination report. These reports do not document the Veteran's shrapnel injuries. On subsequent April 1986 VA examination, it was noted that the Veteran was in Vietnam for 11 months in 1969 during which time he had superficial shrapnel wounds of the right arm, right leg, right thigh and left foot as a result of a hand grenade. He reportedly was placed in the hospital for 14 days during which time he had surgery for removal of fragments under anesthesia. He went back to regular duty for an additional 9 to 10 months of Vietnam service. The April 1986 VA examiner found that the Veteran had a history of shrapnel wounds in the right thigh, right leg, right arm and left foot. He noted that all scars were not attached, that there was no muscle mass deficit, restriction or defacement. VA mental health treatment notes from April 2006 to September 2006 show that the Veteran was receiving mental health treatment during this time frame. A May 2006 VA psychosocial assessment indicates that the Veteran reported that he enjoyed hunting, fishing, playing video games and golfing. Mental status examination showed that the Veteran was alert and oriented and his thought process was coherent. He was tearful at times and kept his head down a lot during the interview. His mood was depressed with a sad affect. He denied any suicidality, homicidality or psychotic symptoms. He reported only sleeping two to three hours per night. He also reported symptoms of feelings of sadness, crying spells, poor energy, decreased sleep pattern, feelings of helplessness, hopelessness, worthlessness, flashbacks almost daily, nightmares, avoidance of reminders of trauma, avoidance of friends that were in the war with him, social isolation, decreased interest in activities, difficulty concentrating and increased irritability. A July 2006 VA progress note shows that the Veteran was noted to cry when someone just started talking about the war. Mental status examination showed a euthymic, sad and tearful mood. The Veteran did not know the date or day of the week and had difficulty with serial 7s. The examining nurse noted that these results may have been affected by the Veteran's emotional state at that moment. The diagnostic impression was depression NOS and a GAF score of 55 was assigned. An August 2006 VA mental status examination shows that the Veteran was noted to have a closed body posture, labile affect and depressed mood. The rest of the mental status examination was within normal limits. A May 2006 private progress note shows that the Veteran was working when a fellow worker was killed by a nail gun. The Veteran was very upset, his blood pressure was very high and he could not sleep. In an October 2006 letter, a private physician noted that the Veteran stepping on the land mine in service had resulted in injury to the right arm and leg. Since that time he had had chronic pain and numbness in the right arm and leg. He did have use of the right arm and leg but they were weaker. As a further result of the war injuries, the Veteran had chronic anxiety and depression, which required him to take anti-anxiety medications and antidepressants. He also required daily pain medications. He was totally and permanently disabled. An October 2006 SSA mental residual functional capacity assessment concluded that the Veteran appeared capable of understanding and carrying out instructions and could maintain attention and concentration adequately for two hour periods within an eight hour work day. He could complete a normal work week without excessive interruptions from psychological symptoms and could interact appropriately with coworkers and supervisors on a limited basis and could adapt to a work setting. On November 2006 VA psychological evaluation, the Veteran reported that he continued to visit with his mother frequently. He also would see his brother on occasion. Additionally, he had fairly regular contact with his three children. The Veteran had worked as a house painter almost all of his adult life. He had last worked in May 2006. The Veteran presented for the evaluation dressed in neat, clean appearing casual attire and his hygiene and grooming were good. His speech was delivered in a moderate tone and pace and the content was rational and goal-directed. No frank hallucinations were reported although the Veteran did continue to experience sensory anomalies as part of his PTSD symptomatology. His mood was cooperative and congenial. His affect ranged from euthymic to warm smiling on a few occasions. General cognitive abilities appeared intact and he had no apparent memory problems during the interview. He had trouble sleeping at night because of dreams and nightmares. He tended to toss and turn all night and said that his wife had given up sleeping with him because of his movements in the bed. He would wake up in a cold sweat. He reported not as many symptoms during the day but they were vivid. Once when he was hunting he thought he saw Vietnamese troops crossing the river coming toward him. He continued to have problems with depression a great deal of the time but the depression appeared to be about equally related to his PTSD and his physical problems. He said that his pain was often quite bad and this put him into a depressed state. He had pain in his arms and back and his right leg was often numb. He and his wife mostly stayed around the house but they would go to the casinos once in a while. They did not attend church. The Veteran had enjoyed deer hunting in the past but said that was now limited due to his pain. He did enjoy fishing. He was fully responsible for his self-care activities. He also would cut the grass and help out around the yard. His wife primarily did the shopping although sometimes he would come along. His wife also handled the finances. The examiner noted that the Veteran appeared clearly competent to manage his financial affairs. He also noted that the Veteran did drive a car. The examiner commented that the Veteran appeared moderately impaired overall due to his PTSD. The examiner noted that there may be short periods when the Veteran has more serious symptoms but overall he would rate him as moderately impaired. The diagnosis was PTSD by established history and continued symptoms and depressive disorder associated with both PTSD and physical problems/pain. A GAF score from 51 to 55 was assigned with some periods of functioning in the serious range. On a November 25, 2006, VA examination, it was noted that the Veteran sustained the shrapnel wound injury on May 7, 1970, injuring his right arm, right thigh and right leg below the knee. The Veteran was hospitalized and underwent surgical debridement with secondary closure of his wounds. He currently had complaints of arm problems. Specifically, he reported having decreased arm strength is his right upper extremity. He also had pain in his arm that was intermittent in nature. The pain was 5/10 in intensity when it was present. It would happen while working but was not necessarily present when he was resting. He was not taking any anti-inflammatory medications but he did have a prescription for Tramadol for pain. His arm did not interfere with his activities of daily living. He had stopped working as a painter because he was told that he had bilateral carpal tunnel syndrome and that he needed to be on disability. He did not use a brace or an assistive device. He could walk a mile without any difficulty. There had been no additional flare-ups. The Veteran did not report any symptomatology associated with the right thigh other than having a feeling of numbness below the knee. The thigh specifically did not have any problem. It did not interfere with his activities of daily living, he did not take any medicines for it and he was not seeing a physician for treatment of it. Regarding his right leg below the knee, the Veteran did not really report any significant pain. He did report experiencing numbness that had been present over the past 8 or 9 years. He indicated that he did not experience pain because the leg was numb. The problem did not interfere with his activities of daily living. He had not seen a physician about the problem. Physical examination of the right upper extremity revealed it to be sensate to light touch in all dermatome distributions. The Veteran was able to flex, extend and abduct his fingers. Examination of the right arm revealed a 6 cm scar along the posteromedial aspect of the arm. It was not fixed to the underlying tissue. It was mildly tender to palpation. There was no erythema. It was mobile. The Veteran also had a small puncture scar on the medial aspect of the elbow. It was not fixed to underlying tissue and was nontender to palpation. There was also a 3 cm longitudinal scar along the ulnar border of the forearm. It was mildly tender to palpation and was not fixed to underlying tissue. There was no erythema or sign of infection. Elbow range of motion was from 0 to 120 degrees. Active and passive range of motion were the same. There was no change with repetition and no pain on range of motion. Range of motion of the right shoulder was 0 to 170 degrees of forward flexion with 120 degrees of abduction, 90 degrees of external rotation and 80 degrees of internal rotation. Active and passive range of motion were the same. There was no change with repetition and no pain on range of motion. Examination of the right lower extremity revealed decreased sensation diffusely over the dorsum and plantar aspect of the foot as well as leg inferior to the knee. Motor functioning was grossly intact. Examination of the right thigh revealed a scar over the posterior aspect of the mid thigh that was approximately 2 cm in diameter. It was not fixed to the underlying tissue. It was mildly tender to palpation. There was no erythema, no drainage, no signs of infection. There was also a scar that was dimpled on the posterolateral aspect of the thigh. It was mildly tender to palpation and was not fixed to underlying tissue and was approximately 3 cm in diameter. There was no sign of infection and no drainage. The compartments were soft and the skin was intact. Examination of the right knee revealed range of motion from 0 to 120 degrees. Active and passive range of motion were the same. There was no change with repetition and no pain. There was no ligamentous laxity appreciated on the knee exam. Examination of the right leg revealed a scar on the anterolateral aspect of the leg that was approximately 3 cm in length. It was not fixed to underlying tissue and was non-tender to palpation. There was no sign of infection and no discharge. There was no erythema. The compartments were soft and the skin was otherwise intact. As reported, there was diminished sensation to light touch diffusely. X-rays of the right humerus, right femur, and right knee revealed no fracture, dislocation or bony destructive lesions. There was mild spurring of the superior and inferior aspects of the patella on the lateral view. There was also mild degenerative change in the median and lateral compartments of the right knee. Joint space appeared to be fairly well maintained. AP and lateral views of the right tibia revealed no fracture, dislocation or bony destructive lesion. The diagnostic assessments were status post soft tissue injury with shrapnel wound to the right arm, soft tissue and injury and shrapnel injury to the right thigh and leg with no muscle loss and mild degenerative changes of the right knee, tricompartmental. The examiner noted that there was mild discomfort associated with the examination of the right arm, right thigh and right leg. It was conceivable that pain could further limit function as described, particularly with repetition. However, it was not feasible to express this in terms of additional limitation of motion as the matter could not be determined with any degree of medical certainty. In a February 2007 decision, SSA found that the Veteran was disabled since May 2, 2006. The Veteran was found to have the following severe impairments: bilateral carpal tunnel syndrome, hypertension, degenerative disc disease, degenerative joint disease and depression. It was noted that the Veteran had arthritis in the knee joints, chronic low back pain and depression with decreased activities. His GAF score was noted be 55. Due to his mental disorder, he was noted to have mild restriction of activities of daily living, mild difficulties in maintaining social functioning, moderate difficulties in maintain concentration, persistence or pace and no episodes of decompensation. A May 2007 private progress note shows that the Veteran reported that he was not sleeping. He was prescribed Ambien and Ativan. In a March 2008 notice of disagreement, the Veteran indicated that his right leg had numbness. The leg would ache and then become numb. He noted that the numbness was around the area of his shrapnel wounds. On August 2008 VA mental health evaluation, the evaluating social worker noted that the Veteran and his wife virtually had no social life. They rarely went out to eat and they did not go to church. Every so often, they would go to a garage sale together. The Veteran had a few Vietnam friends who would call from time to time. He and his wife described a compatible relationship. They enjoyed each other and had little conflict. The Veteran did not participate in any treatment for PTSD. He had been taking medication but had a bad experience with one and stopped taking it. He reported that he continued to have problems with flashbacks a couple of times per month, weekly nightmares, nightly sleep problems and bouts of depression. His wife explained that the couple could not sleep together due to the Veteran's nightmares and thrashing. She feared that he would inadvertently hurt her. He indicated that he was depressed all of the time and cried for no reason. He had no joy in his life. He did not do the activities, like hunting and fishing that he used to do due to his PTSD and chronic pain. He denied high levels of anxiety or ritualistic behavior. His predominant complaint seemed to be living a joyless life. Mental status examination showed that the Veteran was appropriately dressed and cooperative. His mood was dysthymic and his affect was restricted. His speech was slow and soft. A couple of times he had to be asked to repeat what he said. He cried a number of times in the session when talking about why he refused to participate in treatment for PTSD. There was no evidence of an illogical or delusional thought process. Insight and judgment appeared fair. The Veteran denied being suicidal or homicidal. He just appeared to be a lonely, joyless man. The diagnosis was PTSD, moderate to severe. A GAF score of 55 was assigned. The social worker found that the Veteran was competent to handle his finances. The examiner commented that the Veteran continued to have problems with flashbacks, bouts of depression, sleep disruption and disturbing nightmares. He spent much of his time at home watching TV and had little interest in socializing with others. He and his wife had a satisfying relationship. The social worker commented that the Veteran's symptoms appeared to be on about the same level as when he presented for his last examination. On August 20, 2008 VA medical examination, the Veteran reported numbness in the right lateral lower leg and indicated that he started having the problem in 1988. The onset of the numbness was gradual and it went from lateral lower leg to the anterior lower leg. The numbness worsened at night. Standing and walking made the numbness worse. Regarding the Veteran's scar on the right thigh, the examiner noted that the scar had been stable and the Veteran had not received any medical treatment for it. The examiner commented that there was no significant muscle loss and no muscle dysfunction of any significance. The Veteran did not have any braces or assistive devices. He could walk at his own pace for a distance of approximately 1/2 mile at which point the numbness in his right leg would become worse. The examiner noted that the Veteran's shrapnel wounds came from the mine explosion, that he was kept at the hospital for 13 days and that the injuries were to the right arm, right thigh and right leg. The examiner noted that there was no muscle loss in any of the areas around the shrapnel wounds. He noted that the wounds the Veteran received were not through and through injuries and the wounds did not become infected. There were no associated bone, nerve, vascular or tendon injuries. Currently, the Veteran did not have pain, decreased coordination, increased fatigability, weakness or uncertainty of movement. The only symptom he did experience was numbness along the lateral and anterior aspect of the lower right leg. He did not complain of any problems in the right arm or right thigh. There were no flare ups of muscle injury residuals. As far as Deluca criteria were concerned, the examiner found that there was no effect of repetitive motion of the right hip, right knee, right elbow and right shoulder. There was no significant hand or wrist dysfunction associated with the shrapnel injuries. The examiner commented that the wounds from the shrapnel did not appear to have caused any significant muscle loss in either the right arm or leg. No specific muscle groups were affected since the injury appeared to be of the shin and the underlying tissue. The examiner found that the Veteran's muscle function was normal. The examiner noted that the Veteran's numbness was a residual of nerve damage. He noted that the Veteran had an area of decreased microfilament of the right lower lateral leg, which measured 7 inches by 2 inches. There was no muscle loss and there was no muscle dysfunction. Straight leg raising was positive of the right at 10 degrees due to low back/spine condition and unrelated to the muscle injury. The Veteran had intermittent pain of 3/10 in the upper right arm but was asymptomatic during the examination. The examiner found that the Veteran's numbness in the right lower leg had a mild effect on chores, shopping and traveling and prevented exercise, sports and recreation. The Veteran was still able to drive a car. On an August 20, 2008, VA scars examination, the Veteran was noted to have a scar on the upper posterior of the lateral right thigh. The maximum width was 1 centimeter and the maximum length was 2 centimeters. There was no tenderness to palpation and no adherence to the underlying tissue. The scar did not result in limitation of motion or loss of function. There was underlying soft tissue damage and there was not skin ulceration or breakdown over the scar. There was another scar of the right lower extremity, anterior surface. The maximum width was 2.5 cm and the maximum length was 1.5 cm. There was no tenderness on palpation and no adherence to underlying tissue. The scar did not result in limitation of motion or loss of function. There was underlying soft tissue damage and there was no skin ulceration or breakdown over the scar. There was also a scar of the right lower later thigh. The maximum length was 2cm and the maximum width was 1.5 cm. There was no tenderness on palpation and no adherence to underlying tissue. There was no limitation of motion, no underlying tissue damage, no loss of function and no skin ulceration or breakdown. There was also a scar of the right anterior lower leg. The maximum width was 1.5 cm and the maximum length was 3 cm. There was no tenderness to palpation and no adherence to underlying tissue. The scar did not result in limitation of function. There was underlying tissue damage and there was not skin ulceration or breakdown over the scar. There was also a scar on the right lateral lower arm. The maximum width of the scar was .5 cm and the maximum width of the scar was 3 cm. There was no tenderness on palpation and no adherence to underlying tissue. There scar did not result in limitation of motion or loss of function. There was underlying soft tissue damage and there was no skin ulceration or breakdown over the scar. There was another scar identified by the examiner; however, he did not identify the location or total area of the scar. He noted that the scar was not tender to palpation, was not adherent to underlying tissue and did not result in limitation of motion or loss of function. There was underlying tissue damage, however. The examiner estimated that the total estimated body surface area for all of the scars was .5% based on the rule of nines. In an August 2009 rating decision, the rating for the Veteran's PTSD was increased to 50% effective August 29, 2006. On October 2009 VA scars examination, it was noted that the Veteran had not had any symptoms from his scars since they healed in 1970. He denied any pain at the sites requiring any pain medication, skin breakdown, inflammation, infection or any other issues. He reported leg numbness in the last two to three years only and he also reported that he had had lumbar degenerative disc disease and chronic low back pain for the past two to three years. He had not talked to his doctor about the numbness. Physical examination showed a linear scar on the right arm on the extensor aspect proximally. It measured 9.5 cm in length and 1 cm in maximum width. It was mildly hypopigmented as compared to his skin. It was more or less linear. The scar was superficial but not painful on examination. There was no skin breakdown or limitation of function caused by the scar. There was no inflammation, edema or keloid formation. There was also a scar on the right forearm distally on the extensor aspect measuring 3.5 cm in length and .5 cm in maximum breadth. It was linear and nontender. There was no skin breakdown and the scar was superficial. There was no limitation of function caused by the scar. There was no inflammation, edema or keloid formation. There was a tiny hole measuring .3 cm in diameter at the right elbow on the medial aspect. The Veteran reported that there was shrapnel there, which eventually came out. It was not a prior wound requiring stitches. Hence, it was not really a scar but a deficit left there because of the spontaneous removal of the shrapnel at the site. It was nontender. There was no skin breakdown and it was superficial. There was no limitation of function caused by the scar. There was no inflammation, edema or keloid formation. There was a scar on the right thigh on the lateral aspect. It could not be described as linear but was irregular in shape only, measuring 3.5 cm in length and 2.5 cm in maximum width. It was slightly depressed. It was was nontender and superficial and there was no skin breakdown. There was no limitation of function caused by the scar. There was no inflammation, edema or keloid formation. There was a scar on the right leg laterally, which was barely visible and measured about 3cm in total length and 1 cm in maximum breadth. It was roughly oval in shape and was nontender. It blended in with the skin. There was no skin breakdown. The scar was superficial. There was no limitation of function caused by it. There was no inflammation, edema or keloid formation. The diagnostic impression was scars, which had been asymptomatic since they had healed in 1970. The scars caused no limitation to obtaining or maintaining gainful employment. On October 14, 2009 VA psychological evaluation, the Veteran stated that he felt bad all the time. He did not engage in many activities and had difficulty making decisions. He reported feeling depressed and thought about suicide sometimes. The Veteran reported attempting suicide a couple of times prior to his marriage. Concern for his wife and kids prevented him from acting on any suicidal thoughts currently. He also reported feelings of worthlessness. He related not being able to work due to spinal disorder. He described difficulty feeling pleasure. He did not feel hopeful about his future. He reported that he had days when he stayed in bed and did not shower or shave due to his depression. The Veteran's wife reported that the Veteran had night terrors and dreams of monsters that he could not get rid of. He also complained of images of dead people at the end of his bed. She reported that he got drunk twice a week and that his drinking had gotten worse over the past few months. The Veteran reported no concerns with his relationship with his wife. He had grown children and saw them often. Sometimes he would enjoy these visits. He had no other family relationships and denied having any friends. He spent most of his time at home watching TV. Mental status examination showed that the Veteran was clean and neatly groomed. He was restless and noted to be in physical pain. His speech was unremarkable and he was cooperative. His affect was normal and his mood was depressed and dysphoric. He was not able to do serial 7s or spell "world" backwards. He was fully oriented and his thought processes and content were unremarkable. He did not exhibit any delusions and understood the outcome of his behavior. He also partially understood that he had a problem. He had sleep impairment in the form of initial and middle insomnia related to pain and Vietnam related nightmares. He did not have hallucinations, inappropriate behavior, obsessive, ritualistic behavior, panic attacks or homicidal thoughts. His impulse control was good. He had not had episodes of violence and he was able to maintain personal hygiene. The Veteran reported that he had nightmares one to two times per week adversely affecting his sleep. His wife continued to sleep in another room. He had had flashback type experiences when fishing and exhibited emotional distress at reminders of Vietnam. He avoided watching Army movies. He avoided hunting because this would trigger Vietnam memories. He reported feeling distant, detached and emotionally numb. He described a sense of a foreshortened future. He noted that his wife thought he was irritable but he tired to hold in his anger. He reported concentration and attention problems, indicating it was difficult for him to remember doctor's names. He was always on alert and reported exaggerated startle response. The examiner found that the Veteran was capable of managing his financial affairs although he reported that he did not think he would be able to manage them if something happened to his wife. The examiner diagnosed the Veteran with PTSD, chronic, and alcohol dependence. She assigned a GAF score of 45 and noted that it was likely that the PTSD was the primary reason for the Veteran's current level of distress. She found that total and occupational impairment due to PTSD signs and symptoms was not present. However, she did find that PTSD signs and symptoms resulted in deficiencies in most areas. During an October 2009 Decision Review Officer (DRO) hearing, the Veteran testified that he was not currently taking any medications because of problems he experienced with a VA treating psychiatrist. He reported anxiety, irritability, and nightmares a couple of times per week. He also reported continued flashbacks, sleep problems and bouts of depression. His wife reported that the nightmares were more frequent, that he was too paranoid to go hunting, that he would drink as a form of self-medication and that he no longer cared about taking care of the house or yard. She also indicated that his memory was terrible, that he was very depressed and that he had simply lost interest in activities. Regarding his shrapnel wounds, the Veteran reported the numbness in the lower leg, which he indicated was relatively constant. He noted that the shrapnel wounds in the thigh and the arm did not exactly hurt. In a May 2010 rating decision, the RO granted an increased, 70 percent rating, for PTSD effective October 14, 2009. During the March 2011 Board hearing, the Veteran testified that his initial injury involved shrapnel in his entire arm from the elbow to the wrist. He also had shrapnel, which came in to the back of his thigh and came out the front. Other shrapnel went in right below his knee, which was taken out. He noted that his right leg, below the knee, caused him a lot of problems. When asked if he had regained full feeling in the leg after incurring the shrapnel wound, the Veteran reported that he had not. He felt that the problem was like a chronic toothache; it would never go away. He almost always experienced numbness in the area, even when just sitting at the hearing. He often experienced a sensation that his knee was going to give way, particularly if he was going up or down the stairs. Additionally, pain would radiate down from the area to the foot and his toes would get numb. As for the right arm, he experienced some pain and numbness but it did not really result in any impairment. It was just a little aggravating. The pain tended to be worse when there was bad weather and the Veteran indicated that he had arthritis. Additionally, he indicated that he did not have much of a problem with his thigh. Regarding the PTSD, the Veteran reported that he had depression all the time, sleep problems, suicidal thoughts, persistent re-experiencing of traumatic events, numbing of general responsiveness, anxiety without panic attacks and nightmares maybe once or twice a week. He stayed at home most all of the time and felt detached from others. He no longer went fishing or hunting. Overall, he just did not have any interests, hopes or dreams. His wife testified that the Veteran had no social life. He did not go to the grocery store, did not do other shopping and did not pay bills. The Veteran noted that he did mow the grass because he felt that he had to. He did not go to visit his children although they did sometimes come to visit him. He also reported that he use to have problems getting along with supervisors and co-workers when he was still working. III. Law and Regulations Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a Veteran. 38 C.F.R. § 4.3. A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). IV. Analysis A. Ratings for PTSD The 50 percent rating for the Veteran's PTSD has been assigned pursuant to Diagnostic Code 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 50 percent rating is assigned 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. A 70 percent rating is assigned 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. A 100 percent rating is assigned 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. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Prior to October 14, 2009, the Veteran's PTSD was manifested by depressed mood, feelings of sadness, crying spells, poor energy, decreased sleep, feelings of helplessness, hopelessness and worthlessness, sensory anomalies, flashbacks almost daily, nightmares, night sweats, avoidance of reminders of trauma, avoidance of friends that were in the war with him, social isolation, decreased interest in activities, difficulty concentrating and increased irritability. The Board finds that the impairment from this symptomatology was most compatible with assignment of a 50 percent rating for occupational and social impairment with reduced reliability and productivity. In this regard, the Veteran clearly exhibited disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and some level of impaired judgment. A higher, 70 percent rating is not warranted, as the Veteran was not shown to have the more severe level of symptomatology compatible with occupational and social impairment with deficiencies in most areas. In this regard, the Veteran was not shown to have chronic obsessional rituals interfering with routine activities, speech intermittently illogical, obscure or irrelevant, near continuous panic or depression affecting his ability to function independently, appropriately and effectively, spatial disorientation, neglect of personal hygiene or suicidal ideation. Notably, the Veteran did show some level of irritability. However, it is significant that the evidence does not show that he has ever had any intention to harm anyone and he did not describe any thoughts about harming others. Accordingly, he is not shown to have the severe level of impaired impulse control compatible with a 70 percent rating. Additionally, although the Veteran certainly showed difficulty with relationships, there's no indication that he was more broadly unable to establish and maintain effective relationships. In this regard, he continued to maintain his relationship with his wife and his children. Further, although the Veteran was shown to exhibit difficulty in adapting to stressful circumstances, given that the other types of chronic symptomatology generally associated with a 70 percent rating were not shown, the Board finds that the overall symptomatology is more compatible with a lower, 50 percent rating. In this regard, the Board finds that although the Veteran's PTSD was shown to result in severe deficiencies in occupational functioning and mood, it was not shown to result in severe deficiencies with family relations, judgment or thinking. 38 C.F.R. § 4.130. The Board also notes that prior to October 14, 2009, the Veteran was assigned GAF scores ranging from 51 to 55. GAF scores from 51 to 60 tend to indicate moderate symptoms (e.g. flat affect and circumstantial speech and occasional panic attacks) or moderate difficulty is social, occupational or school functioning (e.g. few friends, conflicts with peers or co-workers). Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Thus, as these scores generally indicate a moderate level of impairment, they are also compatible with assignment of no more than a 50 percent rating. From October 14, 2009, the Veteran's PTSD has been manifested by symptoms of social isolation, indecisiveness, depression, depressed and dysphoric mood, sense of foreshortened future, feelings of worthlessness and hopelessness, suicidal ideation, difficulty feeling pleasure, sleeping problems, flashbacks, nightmares, detachment, emotional numbness, irritability, concentration and attention problems and exaggerated startle response. These symptoms have resulted in occupational and social impairment with deficiencies in most areas. Total occupational and social impairment has not been shown. The Board finds that the impairment from this symptomatology is compatible with assignment of no more than a 70 percent rating for occupational and social impairment in most areas. A higher, 100 percent schedular rating, is not warranted as the Veteran is not shown to have 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. In this regard, although the Veteran may have some difficulty remembering things, he is not shown to have forgotten the names of close relatives, his prior occupation or his own name. Also, he has been shown to be oriented to time and place. Additionally, although the Veteran has recently chosen to sometimes stay in bed and not shower, there is no indication that he is unable to take care of his activities of daily living. Further, although he has had some suicidal ideation, there is no indication that he is in persistent danger of hurting himself. 38 C.F.R. § 4.130. The Board also notes that from October 14, 2009, a GAF score of 45 has been assigned. GAF scores between 41 and 50 tend to indicate 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). Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Consequently this assigned score is also not compatible with a 100 percent rating as it clearly refers to serious impairment is social and occupational functioning rather than total impairment in occupational and social functioning. Also, more generally, while the Veteran could have total occupational impairment due to his PTSD, he is not shown to have total social impairment as a result of it. In this regard, he has still been able to continue living with his wife and has also been able to maintain some relationship with his children. Accordingly, from October 14, 2009, the Board finds that the criteria for the assignment of a 100 percent rating for PTSD have not been met. The Board has considered the private physician's statement that the Veteran is totally disabled due to his service connected psychiatric disorder. This opinion is not substantiated by any other evidence on file. As noted above, appellant does not meet the criteria for a 100 percent rating. Moreover, he has been awarded SSA benefits on the basis of primarily non-service connected disorders, including carpel tunnel syndrome and back impairment. The other evidence on file, as discussed above, does not warrant a rating in excess of that assigned for the applicable periods. B. Ratings for service connected shrapnel wounds of the right leg, right arm and right thigh The Veteran's shrapnel residuals have been evaluated under Code 7805, which provides that other scars are to be rated on limitation of function of the affected part. 38 C.F.R. § 4.118 (2008). Other potentially applicable rating codes are Code 7802, which provides a 10 percent evaluation for an area or areas of scars of 144 square inches (929 square centimeters) that do not cause limitation of motion. Code 7803 provides a 10 percent rating for superficial unstable scars. Note (1) to Code 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Code 7804 provides a 10 percent rating for superficial scars that are painful on examination. Note (1) to Code 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. The Board notes that on September 23, 2008, VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The amendments are only effective, however, for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria. In this case, the RO has already considered the Veteran's claim under the old and the new rating codes, and has notified the Veteran of this in the February 2009 statement of the case. Therefore, the Board will also consider the Veteran's claims under the old and new rating codes. The new version of 38 C.F.R. § 4.118, Code 7805 states that for other scars, and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804, any disabling effects of a scar not considered under diagnostic codes 7800-04 are to be rated under an appropriate diagnostic code. The Board notes that the current version of rating code 7800 is not applicable, as it applies only to scars of the face and neck. 38 C.F.R. § 4.118, Code 7800. Under Diagnostic Code 7801, scars, other than head, face, or neck, that are deep and nonlinear in an area or areas exceeding six square inches (39 square centimeters) but less than 12 square inches (77 square centimeters) warrant a 10 percent evaluation. This rating code also provides for higher evaluations based on larger scars. 38 C.F.R. § 4.118, Diagnostic Code 7801. Under Diagnostic Code 7802, scars, other than head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 square centimeters) or greater warrant a 10 percent evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7802. A superficial scar is one not associated with underlying soft tissue damage. Id. at Note (1). Under Diagnostic Code 7804, one or two scars that are unstable or painful merit a 10 percent rating. Three or four scars that are unstable or painful merit a 20 percent evaluation. Five or more scars that are unstable or painful are rated as 30 percent disabling. 38 C.F.R. § 4.118, Code 7804. The Board finds that prior to August 20, 2008, the evidence supports compensable, 10 percent ratings for the scars found to be tender (i.e painful) during the November 25, 2006 VA examination. These include the scar on the posteromedial aspect of the right arm, the scar along the ulnar border of the right mid forearm, the scar over the posterior aspect of the right mid thigh and the scar on the poserolateral aspect of the right thigh. Ratings in excess of 10 percent are not warranted for these scars from November 25, 2006, to August 20, 2008, these scars were not shown to be deep or to result in limitation of motion or limitation of function of an affected part. Further, even if they were found to be deep, they did not cover an area exceeding 12, or even 6, square inches. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). The remaining scars of the medial aspect of the elbow and the anterolateral aspect of the right leg were not found to be painful on examination and were also not found to be deep, covering an area exceeding six square inches, unstable, or to result in any limitation of motion or limitation of function of an affected part. Accordingly, there is no basis for assignment of a compensable rating for them under the old criteria. 38 C.F.R. § 4.118, Diagnostic Codes 7802, 7803, 7804, 7805 (2008). From August 20, 2008, none of the scars were found to be painful on examination, deep, unstable, or to result in any limitation of motion or function of an affected part during the August 20, 2008 or October 2009 VA examinations. Also, although the August 20, 2008 examiner did note that there was underlying tissue damage associated with some of the scars (thus suggesting that they were deep), none of these scars, alone or added together covers an area exceeding six square inches and none of the other descriptions on file do not reveal indications that any of these scars were deep. Accordingly, from August 20, 2008, there is no basis for assignment of a compensable rating for any of the scars under the old criteria. As noted above, from September 23, 2008, the Board must also consider whether a compensable rating is warranted for any of the shrapnel scars under the new criteria. However, the October 2009 VA examiner found that none of the scars covered an area in excess of 144 square inches (even when the areas of all scars are combined), were unstable, or resulted in limitation of function of any underlying body part. As noted, past examinations have not shown the scars to be deep. Accordingly, from September 23, 2008, there is no basis for a compensable rating for any of the scars under the new criteria. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. Thus in sum, in regard to the scarring a compensable, 10 percent rating is warranted from November 25, 2006 to August 20, 2008 for the scars of the posteromedial aspect of the right arm, the scar along the ulnar border of the mid forearm, the scar over the posterior aspect of the mid thigh and the scar on the poserolateral aspect of the thigh. From August 20, 2008, a compensable rating is not warranted for any of the shrapnel scars. The Board has also considered whether the Veteran has any other residuals of his shrapnel wounds that might warrant assignment of a compensable rating. Notably, the Veteran has alleged that his right leg numbness results from the shrapnel wound to his lower leg. However, during the October 2009 VA examination, the examiner specifically found that the numbness was most likely related to the Veteran's low back condition. In this regard, although the August 2008 VA examiner appeared to find that the Veteran's numbness was a result of nerve damage, apparently from the shrapnel wound, there is no indication that he considered whether the numbness could result from the Veteran's back disability. In contrast, the October 2009 VA examiner specifically considered both possibilities and then reasonably determined that the numbness was related to the Veteran's back based on the results of his examination and the Veteran reporting that he had been previously told that the numbness was related to his back disability. Accordingly, the Board attaches more weight to the opinion of the October 2009 VA examiner and finds that the evidence does not establish that the numbness is related to the shrapnel wound. The Board has also considered whether a compensable rating could be assigned for underlying muscle injury from the shrapnel wounds. See 38 C.F.R. § 4.73. However, as none of the examiners found any muscle injury or muscle loss and as the October 2009 VA examiner affirmatively found that the Veteran's wounds were asymptomatic, there is simply no basis for a compensable rating for muscle disability. Additional factors that could provide a basis for an increase have also been considered; however the evidence does not show that the veteran has functional loss beyond that currently compensated. 38 C.F.R. §§4.40, 4.45, Deluca v. Brown 8 Vet. App. 202 (1995). Notably, the evidence does not show that any of the shrapnel wounds result in any functional loss. Accordingly, from August 20, 2008, there is no schedular basis for a compensable rating for any of the residuals of the Veteran's shrapnel wound residuals. C. Extraschedular Consideration The Board has also considered whether the Veteran's claims for increase for PTSD and/or residuals of shrapnel wounds should be referred for consideration of an extraschedular evaluation, and has concluded that no such referral is warranted for any of the time frames in question. As explained above, the Veteran's symptomatology is fully contemplated by the pertinent diagnostic criteria. There is nothing in the record to suggest that his disability picture is so exceptional or unusual as to render impractical the application of the regular schedular standards. See, e.g., Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Prior to October 14, 2009, a rating in excess of 50 percent for service connected posttraumatic stress disorder (PTSD) is denied. From October 14, 2009, a rating in excess of 70 percent for service connected posttraumatic stress disorder (PTSD) is denied. From November 25, 2006 to August 20, 2008, individual 10 percent ratings for scars of the posteromedial aspect of the right arm, along the ulnar border of the right mid forearm, over the posterior aspect of the right mid thigh and on the poserolateral aspect of the right thigh are granted, subject to the law and regulations governing the award of monetary benefits. Other scars did not warrant compensable ratings during this time. From August 20, 2008, a compensable rating for service connected shrapnel wounds of the right arm, right thigh and right leg, to include scarring, is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs