Citation Nr: 1233167 Decision Date: 09/25/12 Archive Date: 10/01/12 DOCKET NO. 06-15 764 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period prior to June 2, 2010, and in excess of 50 percent thereafter. 2. Entitlement to an increased (compensable) rating for the residuals of a shell fragment wound (SFW) to the right shoulder consisting of a scar or scars. 3. Entitlement to a rating in excess of 30 percent for residuals of a gunshot wound (GSW) to the left arm. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran had active service from May 1967 to September 1970. These matters come to the Board of Veterans' Appeals (Board) on appeal from January 2005 and April 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In May 2007, the Veteran testified during a videoconference hearing before the undersigned Acting Veterans Law Judge; a transcript of that hearing is of record. In September 2007, the Board remanded these matters for additional development actions. Because the claim for higher initial ratings for PTSD on appeal follows the grant of service connection, the Board has characterized this matter in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disabilities). Although the RO has granted higher staged ratings during the pendency of this appeal for PTSD, inasmuch as higher ratings are available during each period, and a Veteran is presumed to seek the maximum available benefit for a disability, the claims for initial higher ratings remain viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Lastly, the Board notes that during the pendency of this appeal, in a December 2011 rating decision, the RO granted service connection for degenerative joint disease, left acromioclavicular joint, secondary to traumatic GSW injury and fractured left humerus, assigning a 10 percent rating, and for degenerative joint disease, right humerus, assigning a 10 percent rating, and for degenerative joint disease and chronic strain, left elbow, assigned a noncompensable rating. The Veteran was notified of this determination and of his appellate rights, but has not appealed this decision. Symptoms associated with these disabilities, separate and distinct from the disabilities on appeal, have not been considered in the rating decision below. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). FINDINGS OF FACT 1. During the entire course of the appeal, the Veteran's PTSD has been manifested, primarily, by depression, chronic sleep disturbance, nightmares, anxiety, impaired short term memory, irritability and anger, avoidance behaviors, exaggerated startle response, difficulty concentrating, feelings of detachment, and decreased interest in activities; collectively, resulting in occupational and social impairment with reduced reliability and productivity. 2. The Veteran's residuals of a SFW to the right shoulder, consisting of scars, are not deep, productive of an area of at least 6 square inches, are not painful on examination, and do not affect limitation of motion. 3. The residuals of the GSW to left arm is moderately severely disabling, but without limitation of motion of arm to 25 degrees from side; without limitation of elbow/forearm flexion to 55 degrees and limitation of extension to 100 degrees; and, without deep scars and which are not productive of an area of at least 6 square inches, and which are not painful on examination, and do not affect limitation of motion. CONCLUSIONS OF LAW 1. From February 3, 2004, the criteria for an initial 50 percent rating for PTSD, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102 , 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2011). 2. The criteria for an increased (compensable) rating for residuals of a shell fragment wound to the right shoulder consisting of a scar or scars have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102 , 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7801-7805 (2011). 3. The criteria for a rating in excess of 30 percent for residuals of a gunshot wound to the left arm have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102 , 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7804, 4.71a, Diagnostic Codes 5201, 5206, 5207, 4.73, Diagnostic Codes 5305 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to notify and assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. § 3.159 (2011); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in July 2004, April 2006, and in October 2007. The Court provided additional guidance on the content of the notice that is required under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) in claims involving increased compensation benefits. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The U.S. Court of Appeals for the Federal Circuit reversed the Court's holding in Vazquez, to the extent the Court imposed a requirement that VA notify a Veteran of alternative diagnostic codes or potential "daily life" evidence. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Board finds the notices issued to be sufficient notice per Vazquez. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the most recent December 2011 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to each of the claims on appeal. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased ratings 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; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), 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 the Veteran. 38 C.F.R. § 4.3 (2011). The 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). Where, as here, the question for consideration is the propriety of the initial rating assigned following the grant of service connection for PTSD, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The analysis in the following decision regarding the increased rating claims, other than PTSD, are therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). A. PTSD In February 2004, the Veteran submitted a claim of service connection for PTSD. Service connection for PTSD was granted in a January 2005 rating decision, with an initial 10 percent rating. In an April 2006 rating decision, the RO granted an initial 30 percent rating for PTSD, effective from the February 3, 2004 (date of claim). In a December 2011 rating decision, a 50 percent rating was assigned, effective June 2, 2010. The ratings for PTSD have been assigned pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Turning to the rating criteria for PTSD, the Board first observes that the symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Pursuant to the General Rating formula, a 30 percent rating is warranted when there is occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per 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 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 work like setting); inability to establish and maintain effective relationships. A rating of 100 percent 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. For purposes of considering the evidence in connection with the PTSD issue, the Board notes that the Global Assessment of Functioning (GAF) scale is a scale from 0 to 100, reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) ("DSM-IV") (100 representing superior functioning in a wide range of activities and no psychiatric symptoms). See also 38 C.F.R. §§ 4.125, 4.126, 4.130. A GAF scored of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF of 41-50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning. A GAF of 51-60 denotes moderate symptoms (e.g. flat affect, circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF of 61-70 denotes some mild symptoms (e.g. depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g. occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102; Mauerhan v. Principi, 16 Vet. App. 436 (2002) (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels.). An October 2004 VA PTSD examination report reflects that the Veteran presented as quite somber and almost sullen. The Veteran indicated that he has had some intrusive thoughts and dreams about Vietnam. The Veteran stated "they say I have a temper." He indicated that in the past he had flashbacks. The Veteran presented well-dress and well-groomed. His social skills were poor. His speech was well understood. His thought processes were logical, coherent, and relevant. He was well oriented. His affect was flat and blunted. His concentration was excellent. The Veteran indicated that he tends to be somewhat forgetful, although his memory was basically okay. The Veteran sometimes has depression as well as anxiety, he takes medication for sleep and had not problems sleeping at present. He indicated a history of nightmares in the past and anger control problems. He denied any psychotic symptoms. He denied having any risk factors such as suicidal or homicidal ideas. It was the psychologist's opinion that the Veteran minimally has a PTSD syndrome. Overall, he seems to minimize his symptoms, although his wife states that he continues to have them. The diagnosis was mild PTSD, and a GAF score of 70 was assigned. VA medical records show that the Veteran underwent a psychological assessment in January 2005. The record shows that the Veteran complained of being depressed for a long time and described PTSD symptoms to include nightmares, recurrent thoughts, angry outbursts, and is fearful of being in crowds. He stated that he felt numbness of feelings and does not trust anyone. Objective findings were that the Veteran's mood appeared depressed with congruent affects. He does not sleep well due to the nightmares. The Veteran stated that when his first wife died, he felt he could not go on and became suicidal; however, he is not experiencing these feelings anymore. He has remarried and still finds it difficult to relate without anger. The Veteran worked for nineteen years in a bakery which kept his mind moderately occupied, although he was having trouble at that time. A January 2005 VA psychiatric consultation report reflects that the Veteran's symptoms included waking up in the middle of the night, intrusive thoughts that are triggered by helicopters. He remained dysphoric (angry at home). Trazodone helps somewhat. The Veteran was found to be cooperative, coherent, euthymic not psychotic, no violent ideas, mildly depressed, and mental capacity was grossly intact. The diagnosis was PTSD, mild to moderate and rule out depression. A GAF score of 75 was assigned. A July 2005 VA psychiatry record noted some improvement with treatment, but remained dysphoric. The diagnosis was PTSD, chronic, severe, and a GAF score of 65 was assigned. A March 2006 VA psychiatry record reflects that the Veteran complained of insomnia, with two to three hours of sleep at a time. He did feel improvement in dysphoria. The diagnosis was PTSD, chronic, severe and a GAF score of 65 was assigned. An April 2007 VA psychiatry noted that the Veteran was cooperative, coherent, no psychotic, no violent ideas, euthymic, and clear sensorium. He had no subjective distress and no side effects. The diagnosis was PTSD and a GAF score of 80 was assigned. During the May 2007 Board hearing, the Veteran testified that he was halfway numb. The Veteran took an early retirement because the company he worked for went bankrupt. He stated that during the day he did different activities around the house or do errands. As far as hobbies, he might fish with his son. He did not socialize with anybody because he cannot stand to be in a crowd of people. In a crowd, he feels like someone is looking at him or saying something about him. He does attend church. The Veteran had been married to his first wife for about 30 years, until she died in 2001, and then he remarried in 2003. He testified that he finds himself getting angry about mostly any little thing. He just "snaps," and this happens about two or three times a week. The Veteran's wife testified that she wished they could visit neighbors and friend and go to social events, but because of the Veteran's fear they cannot do that. When in a waiting room, the Veteran sits in chairs away from people. She testified that the Veteran gets angry. They go to church together. The Veteran stated he gets up at night, walks through every room, makes sure the doors are locked and looks out the window. He testified that he cannot be around a lot of people and just wants to be by himself. The Veteran was taking medication for his PTSD symptoms and received treatment at the VA. The Veteran testified that he has not been telling his true symptoms during treatment at the VA because he is afraid of what would be done to him (i.e. he saw that a young man had a needle put in him and that scared him ever since). An August 2007 VA psychology record reflects that the Veteran complained of increasing distress including sadness and dreams that awaken him. He was easily upset and did not wish to be with people, avoids crowds and fears most events and novel situations. He sleeps with a 38 that he uses to search the house at night. He denied any close friends and prefers to sit in the hot car, then stay in church longer than necessary. He reflected on being sad, but anxiety was easily present. He was alert, oriented, coherent, and purposeful. There were no signs of hallucinations, delusions, disorganized thought, or suicidal ideation. There was no obvious physiological signs of arousal or anxiety in speech or manner. He was slowed and appeared sad or depressed. He denied interest in much, talks of problems with sleep, denied weight change, and reported guilt and social discomfort. All functional independence measures are performed independently. The diagnosis was PTSD, chronic, by history as manifest by trauma, recollections, phobic avoidance and impairment in life activities for greater than one month. A GAF score of 69 was assigned. In a November 2007 letter, the Veteran's wife stated that he was a loner, and that he gets angry and agitated easily over little things. He had dreams and flashbacks of the war. The Veteran has low self-esteem and never shows or expresses feelings. She also indicated that the Veteran does not like to socialize and does not relate to others. A December 2007 VA psychiatry notes reflects that the Veteran complained of chronic sleep disturbance, daytime sleepiness, fatigue, naps, irritability, anger outbursts, social withdrawal, procrastination, mood swings, out of focus, short term and recall impairment, poor concentration, avoidance, feeling detached, restricted affect, and startled response. The Veteran was alert and oriented times three. His mood was constricted, sad and mildly dysphoric. He denied suicidal or homicidal ideations. The diagnosis was major depressive disorder, personality disorder, not otherwise specified and a GAF score of 70 was assigned. A July 2008 VA psychiatry record notes that the Veteran stated he is still angry with fear of being around other people. He slept a little better, but was awake after four house and had difficulty falling asleep again. He continued to have nightmares. Mental status examination revealed that the Veteran was casually dressed, clean and groomed, and oriented times four. His speech was clear, coherent, and goal directed. His mood was described as depressed and his affect was blunted. He denied any suicidal or homicidal ideations as well as visual and auditory hallucinations. The Veteran was withdrawn and isolative. He had good insight into his illness. His judgment was fair. The diagnosis was PTSD with depressive disorder and sleep disturbances and a GAF score of 70 was assigned. An August 2009 VA psychiatry record reflects that the Veteran stated he was doing "ok" and he slept much better. He did not feel depressed and did not have nightmares anymore expect once in a blue moon. Mental status examination revealed that the Veteran was casually dressed, clean, groomed, alert and oriented times four. His speech was clear, coherent, and goal directed. His mood was described as ok and his affect was appropriate. He denied any suicidal or homicidal ideations or visual and auditory hallucinations. He has good insight into his illness. His judgment is fair. The diagnosis was PTSD with depressive disorder and sleep disturbances and a GAF score of 70 was assigned. A January 2010 VA psychiatry record shows that the Veteran was casually dressed, clean and groomed. He was alert and oriented times four. His speech was clear, coherent, and goad directed. His mood was described as depressed due to neck pain and his affect was restricted. He denied any suicidal or homicidal ideations or visual and auditory hallucinations. He has good insight and has been compliant with his medications. His judgment was fair. The diagnosis was PTSD with sleep disturbance. VA psychology records from January to March 2010 show that the Veteran had continued reports of problems with sleep and awakenings. He continues to present with symptoms of avoidance and anxiety in social settings with crowds as most avoided. A June 2010 VA PTSD examination report reflects that the claims file was reviewed and psychological testing was performed. The Veteran indicated that his current symptoms include anxiety with anxiety attacks, experiencing loneliness and isolates himself from others, depression with suicidal ideation, anger where he screams, calls people names and throws things. He has never had any homicidal ideas. In the past, he has had an auditory phenomena "like someone talking to you." He also indicated startle symptoms, but no nightmares in three years. He has intrusive thoughts only when reminding of Vietnam. The Veteran stated that he has a desire to go fishing, but his VA appointments preclude his leisure activities. On mental status examination, the Veteran presented as someone who is very anxious and seemingly irritated. His thought processes were logical, coherent, and relevant. He was well-dressed and groomed. His speech was well understood. He was oriented to time, place, person, and situation. His affect was flat and blunted. His concentration was good. His short-term memory was poor and he stated that he was very forgetful. His sensorium was cloudy. The VA examiner stated that a review of psychological symptoms results in the endorsement of anxiety, panic, depression, sleep problems, crying spells, anhedonia, and nightmares. The Veteran indicated anger control problems exhibited towards his wife for which he feels remorse. He indicated auditory phenomena as well as paranoia. He indicated suicidal ideas, but no homicidal ideas. He indicated that when someone watches him, he begins to feel paranoid. Problem behaviors include anger, irritability as well as depression and despondency. The Veteran stated that he is socially withdrawn and becomes angry and irritated at his wife and family, for which he feels guilty. The diagnosis was PTSD and mood disorder, not otherwise specified with some cognitive deficiency, which is secondary to his PTSD. A GAF score of 60 was assigned. The VA examiner noted that the Veteran has reduced reliability and productivity in most social areas including his relationship with his family and society and in general. The Veteran reported good results from his psychotherapy, but marginal results from his medication. The VA examiner also concluded that the Veteran did not fit the criteria for unemployability because of his PTSD. He noted that the Veteran could not think of any mental health problems that interfered with his employment during working years and clearly indicated that he stopped working because of his medical problems and the fact that his employer went bankrupt. VA medical records from September 2010 to June 2011 show that the Veteran continued to participate in VA psychology group therapy. A March 2011 VA psychology record notes that the Veteran presented with anxiety depression, anger, and sleep disturbances. The diagnosis was PTSD, chronic and depression. The Board has considered all the evidence of record in light of the criteria noted above, and finds that by resolving all reasonable doubt in favor of the Veteran, that his service-connected PTSD warrants an initial 50 percent disability rating from the February 3, 2004, effective date of the grant of service connection for PTSD. The Board finds that the Veteran's PTSD symptoms are manifested, primarily, by: depression, chronic sleep disturbance, nightmares, anxiety, impaired short term memory, irritability and anger, avoidance behaviors, exaggerated startle response, difficulty concentrating, feelings of detachment, and decreased interest in activities. The Board finds that this symptomatology more nearly reflects occupational and social impairment with reduced reliability and productivity, the criteria for a 50 percent disability rating. The Board emphasizes that during the entire appeal period, there simply is no medical findings of 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 work like setting); or an inability to establish and maintain effective relationships or more severe symptomatology such as to warrant at least the next higher 70 percent rating. While the Veteran has on occasion indicated that he has had suicidal ideations, collectively, the symptoms manifested by the Veteran's PTSD, as described above, do not warrant the next higher 70 percent rating. Moreover, none of the medical evidence of record reflects that medical personnel have determined that the Veteran's PTSD symptomatology resulted in occupational and social impairment with deficiencies in most areas (the criteria for the next, higher 70 percent disability rating). In addition to the absence of most of the symptoms listed in Diagnostic Code 9411 as characteristic of occupational and social impairment with deficiencies in most areas (criteria for a 70 percent rating), the Board also points out that none of the assigned GAF scores, alone, support the assignment of any higher rating during the period in question. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF score is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. The GAF score and the 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). The GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a) . The Veteran has been assigned GAF scores ranging mostly from 65 to 75, with a recent single score of 60. According to DSM-IV, GAF scores between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores between 51 and 60 denote 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). In this case, the GAF scores of 65 to 75 are reflective of symptoms consistent with a lower disability rating than the 50 percent rating being granted in this decision. However, the Board reiterates, as noted above, that the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the evaluation issue; rather, they 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). In this case, the extent and severity of the Veteran's actual PTSD symptoms reported and/or shown during the entire appeal period are suggestive of occupational and social impairment with reduced reliability and productivity, contemplated in the higher, 50 percent rating for psychiatric disabilities, notwithstanding the GAF scores. In light of all the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD symptoms more nearly approximate an initial 50 percent disability rating, but no higher, from the February 3, 2004 effective date of the grant of service connection. B. Residuals of SFW to the right shoulder consisting of a scar or scars The Veteran has been assigned a noncompensable rating for right shoulder scars pursuant to 38 C.F.R. § 4.118 , Diagnostic Code 7805. Initially, the Board notes that the regulations for evaluating disorders of the skin were changed effective October 23, 2008, but only apply to applications for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54708-4712 (Sept. 23, 2008). Because the Veteran filed his claim in February 2004, the revised regulations do not apply to this claim. The pertinent criteria provide that scars, other than on the head, face, or neck, that are deep or that cause limited motion are rated under DC 7801. Under this code, a 10 percent rating is warranted for a scar or scars with an area or areas exceeding 6 sq. ins. (39 sq. cm). A 20 percent rating is warranted for a scar or scars with an area or areas exceeding 12 sq. ins. (77 sq. cm). A 30 percent rating is warranted for a scar or scars with an area or areas exceeding 72 sq. ins. (465 sq. cm). A maximum 40 percent rating is warranted for a scar or scars with an area or areas exceeding 144 sq. ins. (929 sq. cm). Under DC 7802, a 10 percent rating is warranted for scars, other than head, face, or neck, that are superficial and that do not cause limited motion, with an area or areas of 144 square inches (929 square centimeters) or greater. This is the maximum rating for this code. Note (1): scars in widely separated areas, as on two or more extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. Note (2): A superficial scar is one not associated with underlying soft tissue damage. Under DC 7803, a 10 percent rating is warranted for unstable superficial scars. This is the maximum rating for this code. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): A superficial scar is one not associated with underlying soft tissue damage. Under DC 7804, a 10 percent rating is warranted for superficial scars that are painful on examination. Ten percent is the maximum rating for this code. Note (1): A superficial scar is one not associated with underlying soft tissue damage. Note (2): In this case, a 10 percent evaluation will be assigned to a scar on the tip of the finger or toe even though amputation of the part would not warrant a compensable evaluation. Under DC 7805, scars may also be rated based on limitation of function of affected part. Pertinent evidence includes a November 2004 VA scars examination report that noted a well-healed and slightly depigmented scar of the left lower anterior and lateral humeral region, approximately 7 inches long and 5 millimeters wide; connected to above scar is another well-healed 2 inch by 5 millimeters GSW scar of the lower lateral humeral region. There is also a well-healed and slightly depigmented GSW scar of the left distal posterior humeral region, approximately 3 inches long and 6 to 7 millimeters wide. The Veteran stated that he experienced occasional mild residual pain in the above scars, but no evidence of infection, keloid, etc. The Veteran also had a well-healed slightly depressed scar of the right posterior shoulder, approximately 2 inches by 3 millimeters; also oval shaped scar of the right deltoid region, approximately 3/4 by 1 inch. There is also an approximately 4 inch long and 2 millimeter wide scar, well healed and slightly depigmented, right auxiliary region. There is no pain in the scars on examination. No adherence to underlying tissues. Normal texture of the skin. The scars appear stable without elevation or depression. The scars are superficial. No inflammation, edema, or keloid formation. No areas of induration or inflexibility of the skin in the areas of the scars. No limitation of motion or other limitation of function caused by the scars. No disfigurement. The diagnosis was multiple well-healed gunshot wound and shrapnel fragment wound scars of the bilateral shoulders. A July 2010 VA scars examination report reflects that the Veteran has a scar on the top of his right shoulder, that is a flat, oval, wound scar. There was no skin breakdown over the scar and no reports of pain. Maximum width was 3 centimeters and maximum length was 4.5 centimeters. The area of the scar was less than 6 square inches (39 square centimeters). On examination, the scar was not painful, had no signs of skin breakdown, was superficial, had no inflammation, no edema, and no keloid formation. It had no other disabling effects and did not limit motion or function of the extremity. The diagnosis was scar, residual of SFW, right shoulder. The left upper extremity had an L shaped surgical scar. Maximum width was 6 centimeters and maximum length was 12 centimeters. The area of the scar was less than 6 square inches (39 square centimeters). The Veteran reported no pain. On examination, the scar had no signs of skin breakdown, it was deep, had no inflammation, no edema, and no keloid formation. It had no other disabling effects and did not limit motion or function of the extremity. The diagnosis was scar, residual of GSW left arm. In addition, the Veteran had a scar on the posterior upper arm. The maximum width was 4 centimeters and the maximum length was 6 centimeters. The area of the scar was less than 6 square inches (39 square centimeters). The scar was not painful, had no signs of skin breakdown, was deep, had no inflammation, no edema, and no keloid formation. It had no other disabling effects and did not limit motion or function of the extremity. The diagnosis was scar, residual of GSW left arm. Upon review of the entire evidence of record, the Board finds that a compensable disability rating is not warranted. In this case, the scars associated with the SFW to the right shoulder are not described as deep and do not cover an area exceeding 6 square inches, therefore, a compensable rating is not warranted under DC 7801. The superficial scar did not measure an area of 144 square inches and therefore does not warrant a compensable rating under DC 7802. It is not unstable, and thus, does not warrant a compensable rating under DC 7803. It has not been described as painful on examination and does not warrant a compensable rating under DC 7804. In addition, the VA examiner found no evidence of limitation of motion and therefore does not provide for a rating under DC 7805. Based on the foregoing, the Veteran's residuals of SFW to the right shoulder consisting of a scar or scars does not warrant a compensable rating under any of the possible diagnostic codes during the appeal period. The Veteran's statements as to the severity of his symptoms have been considered. However, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). C. GSW Left arm As an initial matter, the Board notes that the 30 percent disability rating currently assigned for the Veteran's GSW left arm, scars is a protected rating as it has been in effect for more than 20 years. In this regard, any disability which has been continuously rated at or above any evaluation of disability for 20 or more years for VA compensation purposes may not be reduced except upon a showing that such rating was based on fraud. 38 C.F.R. § 3.951(b). The 30 percent disability rating was assigned from September 22, 1970, for a moderately severe muscle disability. The criteria for rating muscle injuries is covered under 38 C.F.R. §§ 4.55, 4.56, and 4.73. Muscle injury ratings are not to be combined with a peripheral nerve paralysis rating of the same body part unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). The skeletal muscles of the body are divided into muscle groups. 38 C.F.R. § 4.55(b). A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). The cardinal signs and symptoms of muscle disability are described in 38 C.F.R. § 4.56(c): loss of power; weakness; lowered threshold of fatigue; fatigue-pain; impairment of coordination; and uncertainty of movement. Disabilities are classified as slight, moderate, moderately severe or severe under diagnostic codes 5301 to 5323. 38 C.F.R. § 4.73. These terms are described in 38 C.F.R. § 4.56(d). A slight disability of muscles stems from a simple wound of a muscle without debridement or infection. 38 C.F.R. § 4.56(d)(1)(i). It heals with good functional results, is superficial, results in minimal scarring and shows no impairment of function or retained metallic fragments. 38 C.F.R. § 4.56(d)(1)(i)-(iii). There are no cardinal signs of muscle disability. 38 C.F.R. § 4.56(d)(1)(ii). For moderate disability, the type of injury is "through and through" or deep and from a single bullet; without explosive effect, residual debridement or prolonged infection. 38 C.F.R. § 4.56(d)(2)(i). The record of moderate disability would show one or more of the cardinal signs and symptoms of muscle disability; particularly the low threshold of fatigue. 38 C.F.R. § 4.56(d)(2)(ii). Objective findings are entrance and exit scars, loss of fascia or muscle substance, and lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2)(iii). Characteristics of moderately severe disability include: a deep penetrating wound; prolonged infection: debridement; prolonged treatment for wound; evidence of inability to keep up with work requirements; entrance and exit scars through one or more muscle groups; loss of deep fascia; and impacted strength and endurance. 38 C.F.R. § 4.56(d)(3). Characteristics of severe disability include all of the above plus: evidence of wounds due to large or multiple missiles; shattering bone fracture; extensive debridement; prolonged infection; intramuscular binding and scarring; consistent complaint of cardinal signs; marked scars; obvious loss on palpation; abnormal contraction; X-ray evidence of multiple scattered foreign bodies; adhesion of scars; atrophy; adaptive contraction of an opposing group of muscles, etc. 38 C.F.R. § 4.56(d)(4). If present, the following are also signs of severe muscle damage: (A) x-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (B) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum, or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. The Veteran is currently in receipt of a 30 percent evaluation for muscle disability in his left upper extremity, pursuant to Diagnostic Code 5305, which contemplates injuries to Muscle Group V. 38 C.F.R. § 4.73. The function of muscles in this group includes elbow supination (long head of biceps is stabilizer of shoulder joint), and flexion of the elbow. The flexor muscles of the elbow are the biceps, brachialis, and brachoradialis muscles. Under Diagnostic Code 5305, a 30 percent evaluation is assigned for moderately severe muscle injury of the dominant upper extremity, and a 40 percent evaluation is assigned for severe muscle injury. A November 2004 VA bones examination report reflects that the Veteran stated that he experienced mild muscle weakness in the left upper arm musculature, especially with repetitive use. The Veteran has not had any treatment at the present pertaining to the GSW and above humeral fracture. Physical examination revealed no objective evidence of muscle weakness. A July 2008 VA orthopedic record notes that the Veteran had bilateral shoulder impingements. The Veteran complained of increased pain and limited range of motion due to pain after receiving injections. Physical examination of the left shoulder was positive for impingement signs. Tenderness to anterior aspect of the shoulders. No findings pertinent to the muscles was noted. A July 2010 VA examination reports reflect that there was no evidence of significant muscle injury residuals to service-connected right humerus and left shoulder; shell fragment wound right shoulder or GSW left arm. The Veteran had normal muscle strength of 5 out of a possible 5 of all muscle groups, including the injured biceps and triceps with no muscle tissue loss noted. The Veteran had no intramuscular scarring, normal muscle function in terms of comfort, endurance, and strength sufficient to perform activities of daily living. There was no muscle herniation found or loss of deep fascia or muscle substance. It was noted that the Veteran had no motion of any joint limited by muscle disease or injury. It was opined that the Veteran's left shoulder disability was mild to moderate on a day to day basis. Overall, the evidence does not demonstrate that the Veteran's left upper extremity involves a severe muscle injury; rather, the current manifestations, at most, support the current 30 percent rating for a moderately severe muscle injury. The Board finds that the Veteran's disability cannot be described as severe as the objective evidence does not show evidence of wounds due to large or multiple missiles; shattering bone fracture; extensive debridement; prolonged infection; intramuscular binding and scarring; consistent complaint of cardinal signs; marked scars; obvious loss on palpation; abnormal contraction; X-ray evidence of multiple scattered foreign bodies; adhesion of scars; atrophy; adaptive contraction of an opposing group of muscles, etc. The objective findings comport with a moderately severe disability of the muscles. The Board notes that a disability rating in excess of 30 percent is not warranted per DC's 5206 and 5207, as it is not shown that flexion of the forearm/elbow is limited to 55 degrees or extension is limited to 100 degrees. The July 2010 VA joints examination reflects left flexion of the elbow/forearm from 0 to 145 degrees and extension to 0 degrees. Ankylosis is not demonstrated. Likewise, a disability rating in excess of 30 percent is not warranted per DC 5201 as left flexion of the shoulder was to 170 degrees, 10 degrees short of normal. The Board has considered other DCs, but no further increase is warranted. The Board has also considered whether a separate rating for scars is warranted. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Although the scars have been described as deep, none of the scars cover an area exceeding 6 square inches, therefore, a compensable rating is not warranted under DC 7801. The superficial scars did not measure an area of 144 square inches and therefore do not warrant a compensable rating under DC 7802. The areas not unstable, and thus, do not warrant a compensable rating under DC 7803. They are not painful on examination and do not warrant a compensable rating under DC 7804. Lastly, the scars do not cause limitation of motion, and therefore, do not warrant a separate compensable rating under DC 7805. The Veteran's statements as to the severity of his symptoms have been considered. However, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). D. Extraschedular consideration The Board has also considered whether each of the Veteran's claims for an increased rating should be referred for consideration of an extraschedular evaluation pursuant to 38 C.F.R. § 3.321(b)(1) and has concluded that no such referral is warranted. The Veteran's symptoms are fully contemplated by the schedular rating criteria applicable to each disability. A higher rating is available for each disability on appeal; however the Veteran does not meet the criteria for a higher rating. 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. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER From February 3, 2004, entitlement to a 50 percent disability rating for PTSD is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a compensable disability rating for residuals of a shell fragment wound to the right shoulder consisting of a scar or scars is denied. Entitlement to a disability rating in excess of 30 percent for residuals of a gunshot wound to the left arm is denied. ____________________________________________ M.W. KREINDLER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs