Citation Nr: 1320860 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 02-08 886A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to January 29, 2013, and in excess of 70 percent after that date. 2. Entitlement to a compensable rating for residuals of a shrapnel wound to the right shoulder. 3. Entitlement to a rating greater than 10 percent for residuals of a shrapnel wound to the head. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from March 1969 to March 1971. This matter is before the Board of Veterans' Appeals (Board) following two decisions from the Court of Appeals for Veterans Claims (the Court). In a January 2011 memorandum decision, the Court set aside and remanded the portion of a June 2009 Board decision which denied an increased initial rating for PTSD. The June 2009 Board decision also, in pertinent part, remanded the Veteran's TDIU claim. The TDIU claim was not part of the February 2011 Court decision, but is still properly before the Board on appeal here. In November 2011, the Court granted a Joint Motion for Remand (JMR) setting aside the portion of a January 2011 Board decision which denied increased ratings for residuals of shrapnel wounds to the right shoulder and head. The January 2011 Board decision also, in pertinent part, remanded the Veteran's TDIU claim again. The TDIU claim was not part of the January 2011 JMR or Court Order, but is still properly before the Board on appeal here. The issues are originally on appeal from June 2001 and July 2002 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran had a hearing before the Board in August 2004 and the transcript is of record. In February 2012, the Board remanded the claims for additional development. In February 2013, the RO increased the disability rating for PTSD from 30 to 70 percent, effective January 29, 2013. FINDINGS OF FACT 1. For the period prior to January 29, 2013, the Veteran's PTSD was manifested by occupational and social impairment, with reduced reliability and productivity. 2. Since January 29, 2013, the Veteran's PTSD has been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 3. The medical evidence of record does not show the presence of a traumatic brain injury during the appeal period that is related to service. The objective evidence does not demonstrate that the residuals of a shrapnel would to the head result in a disability comparable to migraine headaches. The shrapnel wound scar does not result in any characteristic of disfigurement and is not painful. 4. The Veteran's service-connected right shoulder shrapnel wound residuals are manifested by a superficial scar of not more than one centimeter by one centimeter; the scar is not shown to be poorly nourished, with repeated ulceration, or tender or painful on objective demonstration, unstable, or productive of a limitation of function; range of motion of the right shoulder is full and there is no evidence of more than slight muscle disability. 5. The Veteran's service-connected disabilities have not been shown to be of such severity so as to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. For the period prior to January 29, 2013, the criteria for an increased 50 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124(a), 4.130, Diagnostic Code 9411 (2012). 2. Since January 29, 2013, the criteria for a rating in excess of 70 percent rating for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124(a), 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a rating in excess of 10 percent for the residuals of shrapnel wound to the head have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124(a), 4.118, Diagnostic Codes 7800 - 7805 (2002, 2008, 2012); 38 C.F.R. § 4.124a, Diagnostic Codes 8045, 8100 (2008, 2012); 38 C.F.R. § 4.130, Diagnostic Codes 9304 (2012). 4. The criteria for a compensable rating for residuals of shrapnel wound to the right shoulder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a, 4.118, Diagnostic Codes 5200, 5201, 5301 (2012); 38 C.F.R. § 4.118, Diagnostic Codes 7801 - 7805 (2002, 2008, 2012). 5. The criteria for assignment of TDIU are not met, and the evidence does not warrant referral for consideration of a TDIU on an extra-schedular basis. 38 U.S.C.A. §§1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.340 , 3.341, 4.15, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). Notice was provided in April 2005 and June 2009 and the claims were subsequently readjudicated, most recently in an April 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333. Regulations pertaining to traumatic brain injuries and to skin disabilities changed during the pendency of the appeal. However, with regard to the residual shrapnel wound to the head, the Veteran was notified of the 2002 skin regulations and his appeal was rated under the current skin regulations in the most recent April 2013 supplemental statement of the case. In terms of the criteria pertaining to traumatic brain injury, in June 2009, the Veteran was provided with notice of the new rating criteria. His claim was rated under both the new and old criteria by the RO prior to current Board review. With regard to the residual shrapnel wound to the right shoulder, the Veteran's claim was rated under both the old and new diagnostic criteria, first in the June 2001 rating decision and then in the April 2014 supplemental statement of the case. Accordingly, the Board finds no prejudice with regard to notice of the changed criteria for any of the appealed disabilities, with no resulting prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Relevant to the duty to assist, the Veteran's service treatment records, post-service VA treatment records, Social Security Administration (SSA) disability records, private treatment records, and VA examination reports dated in December 2000, January 2006, February 2008, February 2010, February 2011, and April 2013 are of record. The Veteran has not identified any additional, outstanding records necessary to decide his pending appeal. On most recent remand, the Veteran submitted releases for certain private treatment records and the RO sent two notices to those facilities requesting records, with no response. The RO obtained all identified and available VA treatment records from multiple facilities identified by the Veteran. In compliance with the previous Court remand, the RO contacted the NPRC and, in March 2012, received all available additional service treatment records, including related to the Veteran's hospitalization in Fubai, Cam Ranh Bay hospital in May 1970. The Board has also reviewed the Veteran's Virtual VA claims file, noting documents in the Virtual VA claims file that refer to other separately adjudicated claims, such as for hepatitis and special monthly compensation. The Board has reviewed the VA treatment records on Virtual VA, noting no pertinent evidence that would warrant remand for a supplemental statement of the case. Thus, there is no prejudice to the Veteran in adjudicating his claims. The Board finds that the remand directives have been substantially complied with, and no further action is necessary in this regard. Thus, the Board finds that VA has fully satisfied the duty to assist. Additional efforts to assist or notify the Veteran would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). PTSD The Veteran's PTSD is currently rated as 30 percent disabling prior to January 29, 2013, and as 70 percent disabling thereafter. Under the criteria pertaining to PTSD, a 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. A 70 percent rating is warranted when there is 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 50 percent evaluation is warranted when occupational and social impairment is found 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 30 percent evaluation is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The symptoms recited in the criteria in the rating schedule for evaluating 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, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing The Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating 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). A score of 61 to 70 is defined as indicative of 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. See Carpenter v. Brown , 8 Vet. App. 240, 242- 244 (1995). GAF scores are generally used in examinations reports regarding veterans' psychiatric disabilities. Turning to the evidence of record, on VA examination in December 2000, the Veteran reported recurrent nightmares of his Vietnam experiences, trouble sleeping, irritability, and anger problems. He thought about hurting people and stated that life had no meaning to him. He reported trouble concentrating, but had a vivid memory for Vietnam events. He worked for the Ford Motor Company and lived with his wife and younger daughter. He felt detached from his family and had no close friends. He had had legal trouble due to drinking. He had no close friends. He was hypervigilant. He drank approximately 12 beers per night. On examination, the Veteran was casually dressed and groomed. He was cooperative, alert, and oriented to person, place, and time. His speech was coherent. Mood was depressed and angry. Affect was constricted. Thought processes were goal-directed. There was no evidence of obsessive/ritualistic behavior or hallucinations. There were no homicidal or suicidal thoughts. Judgment was limited and insight fair. The diagnoses were PTSD, chronic; and alcohol dependence. The GAF score was 60. The examiner stated that the Veteran's PTSD symptoms caused significant distress and impairment in his social, occupational, and other areas of functioning. A February 2001 record associated with the Veteran's recovery from a serious motor vehicle accident reflects the diagnosis of organic brain syndrome secondary to closed head trauma. He had a GAF score of 30. A July 2002 private psychological evaluation related to his recovery from the motor vehicle accident reflects that when asked if he had previous trouble at work, prior to the injury, his response was, "Of course I had problems getting along with others at work, everybody does. Nothing dramatic though, just a few fistfights." He stated that he tried to have a positive attitude but lacked strength. He denied crying. His appetite was good. He had trouble concentrating and with memory. He was not suicidal. He reported having nightmares about Vietnam often. He denied having any hobbies. He could complete simple cooking tasks. He socialized everyday with the people he lived with, and on a weekly basis with extended family He drove a few times per week and ate out at restaurants on a regular basis. He was no longer active in terms of completing yard work or chores around the home. He was oriented in all spheres, and was cordial and cooperative. His mood was subdued. He showed little positive emotion. He had adequate attention and concentration and exhibited eye contact. His psychomotor activity was a little slowed but his other sensory functions were within normal limits. His speech was normal and lucid. His thought process and content were normal. His memory was intact. The diagnosis was a cognitive disorder. It was noted that he did not emphasize possible problems with PTSD even though he received disability payments for that disability. He did mention nightmares related to Vietnam. The testing results on examination did not show any significant cognitive problems. With regard to employment, the examiner believed that the Veteran would be able to sustain attention in order to complete simple tasks and would be able to adequately relate to co-workers and supervisors. In December 2003, the Veteran's wife stated that the Veteran often talked in his sleep and would make threats and acted extremely angry towards her. A May 2004 SSA decision noted that the Veteran was disabled from the following "severe" impairments: central cord syndrome; traumatic brain injury; post-traumatic arthritis; and status-post cervical fusion. At his August 2004 hearing before the Board, the Veteran stated that his PTSD had adversely affected his life. Things could set him off and he had bad dreams. He said he could not sit with his back to a door or window. He needed to see who was coming in. Certain noises, like a car backfiring, could trigger his symptoms. He tried to stay away from large crowds of people. His only friend was his brother who lived nearby. He stated that when he worked, he had gotten into fist fights but was able to keep his job because of the union. He reported having short term memory loss and frequent panic attacks when around too many people. He reported that he had worked as a route and shipping clerk and as a union representative until he accepted medical retirement after 26 years of employment. He retired following his traumatic brain injury. He felt that the VA could not differentiate between the severity of his PTSD and the residuals from his traumatic brain injury in terms of his employability. VA treatment records reflect that in October 2005, the Veteran reported flashbacks of the Vietnam war daily and looking under his bed at night. He would drink alcohol in order to fall asleep. On VA examination in January 2006, the examiner stated that the Veteran's PTSD symptoms had worsened in the past five years. The Veteran had experienced an increase in intrusive thoughts to the point that they happened constantly during the day; his nightmares and flashbacks had also increased. The Veteran had also had increased problems sleeping and increased hypervigilance. He was sleeping with a gun under his pillow. He was avoidant of anything or person that reminded him of Vietnam. He reported having a bad temper in the past and not getting along well with others in his previous job. He was currently drinking seven rum-and-Cokes per night. He had lived with his wife of 38 years. They had two children. The examiner stated that the Veteran was on Social Security disability due to "psychiatric and medical impairments." On examination, the Veteran was alert and oriented times four, and well-dressed and well-groomed. His speech was of normal rate, tone, and volume. Mood was dysthymic, affect tearful and mood congruent. Thought processes were linear, logical, and goal directed; there were no loose associations or flights of ideas. The Veteran denied suicidal or homicidal ideation, intent, or plans. He denied auditory, visual, or tactile hallucinations. Recent and remote memory were intact. Cognition was intact. Insight and judgment were fair. The examiner stated that the Veteran experienced severe social dysfunction due to PTSD symptoms and would be considered not employable due to such symptoms. Further, there was no sign of remission or capacity for improvement. The GAF score was 48. In August 2006, the Veteran's wife submitted a statement that the Veteran slept with a machete under his bed, checked all parameters before going to sleep, would always have to sit looking at the door, with the door behind him, and could not dine at any oriental restaurant due to memories of Vietnam. On February 2008 VA examination, the examiner noted no hospitalizations for mental disorder. The Veteran reported being depressed three or four days the past week, for several hours. The Veteran had been married for 40 years and stated that he guessed his marriage was "going all right." He had close relationships with his two children. He also reported that he had two friends. He drank a half-gallon of rum every three days. On examination, the Veteran was clean, neatly groomed, and appropriately and casually dressed. His speech was unremarkable, spontaneous, clear, and coherent. His affect was normal. He was fully oriented. There was no evidence of delusions. The Veteran understood the outcome of his behavior. The examiner noted the Veteran engaged in obsessive or ritualistic behavior in the form of counting. He had no panic attacks or suicidal or homicidal thoughts. There were no episodes of violence. Remote, recent, and immediate memory was normal. The examiner noted the Veteran experienced intrusive memories of Vietnam almost daily; hypervigilance; flashbacks, poor sleep, and anger. The examiner noted that the Veteran had stopped working in 2001 secondary to a motor vehicle accident with resulting head injury. The examiner stated that the Veteran was not unemployable due to PTSD. He had social withdrawal partially due to PTSD and exacerbated by alcohol dependence. The prognosis for improvement of his psychiatric condition was fair to good if the Veteran sought treatment. The examiner stated that the Veteran's PTSD symptoms did not result in deficiencies in the following areas: judgment, thinking, family relations, work, mood, or school. There was no reduced reliability and productivity due to PTSD symptoms. There was occasional decrease in work efficiency and permanent periods of inability to perform occupational tasks due to PTSD signs and symptoms. The GAF score assigned was 60. VA treatment records reflect that on November 2008 psychiatric consultation, the Veteran reported nightmares and flashbacks related to his Vietnam experiences. He avoided crowds and places, was hypervigilent, and was always scanning the environment and facing the exit when out. He reported episodes of depressed mood that lasted from hours to one week. His energy and concentration were good. He denied suicidal or homicidal ideations. Mental status examination was within normal limits. The diagnosis was PTSD, alcohol abuse, and traumatic brain injury. The GAF score assigned was 60. Records dated in 2008 and 2009 reflect that the Veteran attended supportive psychotherapy. He raised such symptoms as not liking to be in crowds and feeling distrustful towards others. A GAF of 60 was assigned at each session. In 2009, he reported that he had started walking and was losing weight. In December 2011, the Veteran reported he was feeling good around the holiday season. He reported that his other doctor was going to state that his PTSD symptoms were worse when he stopped alcohol use and he felt that would give him an increase in disability compensation. Mental status examination was within normal limits. The ongoing diagnosis was alcohol dependence and PTSD. The GAF was 57. On January 2013 VA examination, the Veteran's PTSD symptoms included recurrent and distressing recollections of combat trauma, recurrent distressing dreams of combat, acting or feeling as if the traumatic event were recurring, diminished interest in activities, restricted range of feelings, trouble sleeping, hypervigilance, and exaggerated startle response. The Veteran reported drinking 21-ounces of alcohol a day at night to go to sleep. Mental status examination showed that the Veteran was dressed appropriately, with good hygiene and grooming. He was cooperative. He was alert and oriented in all spheres. His mood was euthymic and congruent. Speech was normal. His thoughts were logical and goal-directed. Judgment and insight were intact. His current symptoms included daily anxiety, suspiciousness, and flattened affect. He was withdrawn and had poor sleep. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 60. The examiner stated that a GAF score of 60 was representative of moderate difficulty in social functioning, problems in interpersonal relationships, and symptoms that disrupted his functioning. It seemed highly likely that such difficulties would be experienced in occupational functioning if the Veteran were to work. The examiner reviewed the GAF scores taken during the appeal period which ranged from 48 in 2006 to 60-65 in 2012. The lower scores, that of 48 and 50, were made based upon an unstructured clinical interview, based solely on the Veteran's subjective report, in the absence of any psychological assessment. On the other hand, the other scores which were 60 and above were based upon structured clinical interviews which were mostly based upon objective psychological assessment measures. The examiner did not find that the stretch from 48 to 65 was significant. Such scores varied overtime with fluctuation of symptoms. It appeared that the vast majority of his GAF scores were in the 55 to 60 range. The examiner stated that it was possible to differentiate between the psychological residuals from the motor vehicle accident and his PTSD related to service. The examiner explained that the Veteran's physical condition was largely related to the 2001 accident with little or no cognitive sequelae. His alcohol use, which the Veteran attributed to self-medicating to get to sleep, contributed to disinhibition of emotions and behaviors, irritability, social isolation, and compromised judgment. It curtailed development of coping mechanisms. Such effects correlated with the many signs and symptoms of PTSD. The examiner determined that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The examiner stated that the detrimental effects of PTSD and alcohol dependence resulted in symptoms like hyperarousal and increased anxiety that resulted in reduced occupational and social functioning. In this case, the Board finds that prior to January 29, 2013, the Veteran's PTSD symptoms were moderate in degree, meeting the criteria for a higher 50 percent rating, but no more. The Board concludes such because dating back to the beginning of the appeal period, the Veteran displayed such moderate symptoms as recurrent nightmares, trouble sleeping, irritability, anger, and social withdrawal. Mental status examination demonstrated fair insight and ongoing depressed mood. His GAF scores were also in more than the mild or mild to moderate range, demonstrating a disability that was more severe than the current 30 percent rating. However, the Board finds that a higher 70 percent rating is not warranted for the period prior to January 29, 2013. When reviewing and analyzing the evidence from that period, on December 2000 VA examination, mental status examination did not demonstrate a severe or moderately severe psychiatric disorder. Rather, the Veteran was cooperative, well-groomed, oriented, and coherent. His thought process was goal-directed and he did not display any ritualistic or obsessive behaviors, or show homicidal or suicidal ideations. His limited judgment and depressed mood were present, but are accounted for in the higher 50 percent rating. Moreover, a GAF score of 60 was assigned, which is indicative of a moderate, rather than severe psychiatric disorder. The same is the case on subsequent VA examinations and as noted in the treatment records. In 2002, while depressed and without energy, he was not tearful and was able to socialize with his family. He left the home to drive a few times per week and dined out regularly. Mental status examination was mostly within normal limits but for slightly slowed psychomotor activity. The Veteran reported similar symptoms at his 2004 hearing, along with parameter checking and having to watch the doors wherever he was located. He reported frequent panic, however, those symptoms have not been documented in any treatment records or examinations. Again, the effects of the symptoms shown are contemplated in the 50 percent rating. On January 2006 VA examination, the Veteran reported an increase in symptoms, including flashbacks, nightmares, and hypervigilance. However, mental status examination showed that the Veteran was oriented, had a dysthymic mood, had normal thought process, and had no loose associations of ideas. He had no hallucinations or suicidal thoughts. His memory was intact. A GAF score of 48 was assigned. The Board has considered this lower GAF score but finds that it is still indicative of a moderate, or 50 percent, disability rating. As the 2013 VA examiner pointed out, the 2006 examination was significant for a subjective, nonclinical interview process which lessens the value of the opinion provided. The Board finds that assessment to hold weight in that the 2006 examination report does not provide any explanation for the lowered GAF score when the mental status examination was mostly intact. Moreover, when comparing the results of that examination with the previous and subsequent exams, the Board finds that it lacks probative weight because such severe conclusions as to the Veteran's social dysfunction were not otherwise found in the records surrounding that examination. As the 2013 examiner pointed out, the Veteran's symptoms fluctuated but, overall, it appeared that the Veteran was functioning at a moderate degree, with GAF scores fitting well in the 55-60 range. Thus, it would not be appropriate to stage a rating based upon the 2006 VA examination as the report itself lacks objectivity and it does not correlate with the VA examinations and treatment records at that time and before that time. In fact, 2008 VA examination appeared to be very similar to the 2000 and 2002 VA examination reports, as well as the mental functioning displayed in 2006. The examiner in 2008 found a moderate psychiatric disability, with a GAF of 60 assigned. Also, the 2008 examiner did not find deficiencies in most areas, but rather found occasional decease in work efficiency. Ongoing VA treatment records dated from 2008 to 2010, and also in 2013, show that the Veteran's GAF scores ranged from the 50s to 60s, and that his mental status examination was mostly within normal limits. He mainly suffered from the same symptoms throughout, such as intrusive thoughts of Vietnam, nightmares, anger, and trouble sleeping. Again, those symptoms are accounted for in the 50 percent rating. They are indicative of obsessional rituals, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, spatial disorientation, or neglect of personal appearance and hygiene. Instead, they are indicative of reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships, as repeatedly found on VA examination. Lastly, the one lower GAF score of 30 following the motor vehicle accident was clearly related to that accident and subsequent recovery, rather than to his PTSD, and is thus not relevant to this analysis. Accordingly, the Board finds that a rating higher than 50 percent for the period prior to January 29, 2013, is not warranted. Since January 29, 2013, for which the Veteran is in receipt of a 70 percent rating, a 100 percent rating is not warranted. At no times has the Veteran' s PTSD been shown to result in total occupational and social impairment. Nor has his PTSD been shown to result in gross impairment of thought process or communication, delusions, grossly inappropriate behavior, or any other symptom listed in the 100 percent rating criteria. Shrapnel Wound, Head The Veteran sustained a shrapnel wound to the head during service in Vietnam in May 1970. The Veteran continues to contend that he is entitled to a higher evaluation. The Veteran's current residuals of shrapnel wound to the head are rated under Diagnostic Codes 5296-8045. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). This hyphenated code may be read to indicate that loss of part of the skull is the service-connected disorder, and it is rated as if the residual condition is traumatic brain injury under DC 8045. The protocol for traumatic brain injuries was revised during the pendency of this appeal. See 73 Fed. Reg. 54,693 (Sept. 23, 2008). The effective date for these revisions is October 23, 2008. 38 C.F.R. § 4.124 , Note (5) (2012). For claims received by VA prior to that effective date, a veteran is to be rated under the old criteria for any periods prior to October 23, 2008, but under the new criteria or the old criteria, whichever are more favorable, for any period beginning on October 23, 2008. The claim is to be rated under the old criteria unless applying the new criteria results in a higher disability rating. See VBA Fast Letter 8-36 (October 24, 2008). However, a veteran whose residuals of TBI were rated by VA under a prior version of 38 CFR 4.124a, Diagnostic Code 8045, will be permitted to request review under the new criteria, irrespective of whether his or her disability has worsened since the last review or whether VA receives any additional evidence. See 73 Fed. Reg. 54,693 (Sept. 23, 2008). In this case, while the Veteran filed his claim for service connection prior to October 2008, he has requested review under the old and new criteria. Therefore, the Board will consider both sets of criteria. Prior to October 23, 2008, brain disease due to trauma under Diagnostic Code 8045, purely neurological disabilities, such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., following trauma to the brain, was to rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045-8207). Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated at a maximum of 10 percent under Diagnostic Codes 9304, "Dementia due to head trauma." This 10 percent rating will not be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Codes 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. 38 C.F.R. Part 4, § 4 .124a, Diagnostic Codes 8045 (2008). The Veteran has been assigned a 10 percent rating based upon his subjective complaints of headaches under the old criteria. Revised Diagnostic Code 8045 states that there are three main areas of dysfunction that may result from TBIs and have profound effects on functioning: cognitive (which is common in varying degrees after a TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a , Diagnostic Code 8045 (2012). Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Turning to the evidence of record, initial VA examination in December 1971 found no current residuals of the head shrapnel wound other than the retained foreign body. On November 1976 VA examination, the Veteran had headaches that were located in the inside of his head on both sides, and caused his eyes to hurt. He took pain pills and aspirin for his headaches. They were frequent and it was hard to keep his eyes open. The diagnosis was shrapnel wound to the head with residuals of small metallic body in the soft tissue of the left posterior parietal area. On VA examination in December 2000, the Veteran reported headaches on and off about twice weekly, lasting for a couple of hours at a time; these were usually alleviated by lying down. He reported that he had been employed by the same employer as a shipping clerk for the previous 27 years. Evaluation of the scalp area showed no tenderness, and palpation did not reveal any foreign bodies. Cranial nerves examination was within normal limits. X-ray of the skull showed a small metallic fragment in the soft tissue adjacent to the left parietal calvarium. In terms of effect on occupation, the examiner found only that during episodes of headaches, he would be dysfunctional, though he was currently working fulltime. In January 2001 the Veteran was injured in a motor vehicle accident in which he was an unrestrained driver. He suffered loss of consciousness and his injuries included frontal and right temporal head contusions. The Veteran remained in a coma for several weeks and a February 2001 treatment record noted that he had been very confused since being extubated following the head injury. In December 2001 he was noted to be continuing a good recovery from functional and cognitive defects of severe traumatic brain injury. At his August 2004 hearing before the Board, the Veteran stated that he had occasional headaches that lasted a few hours which he would treat with a cold rag over his eyes. On VA examination in January 2006, the Veteran reported that he experienced occasional headaches which he thought were more related to his PTSD than anything else. He denied any seizures. On examination, cranial nerves were intact. The examiner did not believe that the motor vehicle accident had worsened the pre-existing head injury. On February 2010 VA examination, the Veteran reported that he did not lose consciousness at the time of the shrapnel injury in 1970 but stated that he had experienced recurrent headaches ever since. The Veteran also reported that following his head injury in 2001 he was in a coma for weeks and then when he regained consciousness, was confused and disoriented, believing he was in Vietnam. The Veteran's daughter reported that he had experienced memory problems since the car accident; she did not recall his having any specific cognitive impairments prior to the 2001 accident. The Veteran reported that his headaches were at least weekly, but not daily. They lasted for several hours and ordinary activity was not possible. On examination, the examiner did not find a visible shrapnel wound on the posterior head even with the Veteran's daughter's help. The examiner diagnosed severe traumatic brain injury due to motor vehicle accident in 2001 with likely residuals of cognitive impairment. It was the examiner's opinion that the Veteran's current cognitive impairment was less likely as not due to the service-connected shrapnel wound to the head and was most likely due to his motor vehicle accident/severe traumatic brain injury in 2001. The examiner further stated that as the Veteran did not report chronic headaches during service and that the current headaches were less likely as not due to his shrapnel wound of the head. VA treatment records reflect that in May 2012, the Veteran was seen status post syncopal episodes. He reported that a radiologist had told him that his episodes were caused by shrapnel in the right front and rear of his brain. He had had numerous episodes. The concurrent records reflect that the Veteran was experiencing syncopal episodes and had a previous traumatic brain injury. The records note the in-service shrapnel wound to the head but do not relate his syncopal episodes/seizures to that wound. The records also document excess alcohol use and he was counseled repeatedly to lower alcohol intake. Seizure episodes were noted with a history of cirrhosis of the liver with hepatic ancephalopathy. On January 2013 VA examination, it was found that the scar on the Veteran's head was not painful or unstable, with no frequent loss of covering of the skin. The examiner was unable to measure the head scar due to hair covering the scar area. The scar was not elevated or depressed. There was no adherence to underlying tissue. There was no abnormal pigmentation. There was no gross distortion or asymmetry. It was concluded that the Veteran's shrapnel wounds to the head and shoulder did not prevent the Veteran from securing or following substantially gainful employment. The biggest obstacle to gaining employment was most likely due to the impairment/cognitive disabilities attributable solely to the post-service January 2001 motor vehicle accident as a CTscan of the head has shown resulting bilateral front lobe encephalmalacia, atrophy. On April 2013 VA traumatic brain injury examination, the Veteran reported that he had suffered from short term memory loss since the brain injury from the shrapnel wound. However, review of the claims file showed that the Veteran was working successfully after active duty with no major complaint except for some symptoms of PTSD and severe alcoholism. Previously, he denied losing consciousness during the shrapnel wound to the scalp. His judgment was normal, his social interaction was routinely appropriate, he was oriented in all spheres, his motor activity was normal, his spatial orientation was normal, and there were no subjective symptoms to report. He did exhibit neurobehavorial affects that occasionally interfered with workplace interaction and social interaction, but did not preclude them. He was able to communicate by spoken and written language. His consciousness was normal. He did not report subjective symptoms such as migraine headaches. After completing neuropsychological examination, it was determined that alcohol abuse was a major factor in his dysfunction and limited ability to cope, increasing his emotional volatility and limiting his rational responses to stress. It was determined that the Veteran's service-connected shrapnel wound did not result in residuals of a traumatic brain injury. The shrapnel wound to the head did not interfere with his ability to work. On April 2013 VA scar examination, the shrapnel scar to the head was measured as 3.5 centimeters by .1 centimeters. There were no abnormal findings related to the scar to differ from the pervious, January 2013 VA examination. Upon review of the above, the Board finds that a disability rating greater than 10 percent for the Veteran's service-connected residuals of shrapnel wound of the head is not warranted. For one, the Veteran does not carry a diagnosis of traumatic brain injury with regard to the shrapnel wound to the head. At no time during the appeal period has the service-connected shrapnel wound to the head been determined to have resulted in a traumatic brain injury. Despite that, the Veteran is already in receipt of a 10 percent rating for headaches stemming from the shrapnel wound injury, even though more recent VA opinion has concluded that his headaches are not likely related to the service-connected head injury. Furthermore, there is no indication of cognitive, emotional/behavioral, or physical, or neurological sequelae resulting from the in-service shrapnel wound. Although on 2013 traumatic brain injury VA examination, the Veteran displayed some neurobehavioral affects that occasionally interfered with workplace interaction and social interaction, the examiner did not relate those symptoms with his service-connected shrapnel wound to the head. Rather, the examiner found no residuals related to the shrapnel wound. Nonetheless, that sole finding would warrant only a 10 percent rating, and the Veteran is already in receipt of a 10 percent rating under the regulations pertaining to traumatic brain injuries. The current rating is for headaches that have been determined to not be related to his service-connected disability, and thus a second 10 percent rating would not be appropriate in this case. Accordingly, a higher rating under the regulations pertaining to traumatic brain injuries is not warranted. The Board further finds that a rating for headaches under the criteria pertaining to migraines, DC 8100, is not warranted. For, as explained by the 2010 VA examiner, it was less likely than not that his headaches were due to the shrapnel wound as the Veteran did not display those headaches in service following the injury. Moreover, the other VA examinations of record do not affirmatively relate his reported headaches with the shrapnel wound, and there is in fact no positive evidence of record to relate such. On 2013 VA examination, no residual was found to relate to the service-connected shrapnel wound. Despite that the Veteran claim that he suffers from headaches and syncope due to the shrapnel wound, a physician has not made that connection. Rather, his syncope has been related to his 2001 motor vehicle accident and/or to his alcohol abuse. Therefore, the Board cannot assign a higher rating under DC 8100, as the objective evidence in this case fails to demonstrate that the Veteran's residuals of a shrapnel wound to the head equate to migraine headaches. Lastly, the Board finds that a separate or higher rating for the residual shrapnel wound to the head is not warranted under the regulations pertaining to skin conditions. At the outset, the Board notes that those regulations had been revised twice, in 2002 and in 2008, since the Veteran filed his claim. In this case, the Board will consider both the "old" and "revised" criteria, construing the claim for increase very broadly to include a request for review pursuant to the change to the rating criteria. The "old" and "revised" Diagnostic Code 7800 provides a 10 percent rating for scars of the head, face, or neck with one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2002 and 2008). A 30 percent rating is provided for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A 50 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent evaluation is provided for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. Under Note (1), the 8 characteristics of disfigurement for purposes of evaluation are as follows: a scar 5 or more inches (13 or more cm.) in length; a scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7800 (2002 and 2008). Under the "old" Diagnostic Code 7804, a 10 percent rating is warranted for superficial scars that are painful on examination.38 C.F.R. § 4.118 (2002). Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage. Id. Under the "revised" Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804 (2008). A 20 percent rating is warranted when there are three or fourth scars that are unstable or painful. A 30 percent evaluation is assigned when there are five or more scars that are unstable or painful. Note (1) indicates that an unstable scar is one whether, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. In this case, the Veteran's shrapnel wound to the head does meet any of the characters of disfigurement and was not shown to be painful. The Veteran has not stated that causes him pain. Accordingly, a separate compensable rating for the residual head scar is not warranted. Shrapnel Wound, Right Shoulder The Veteran's right shoulder shrapnel wound residuals have been assigned a noncompensable disability rating under 38 C.F.R. § 4.73, Diagnostic Code 5301. This diagnostic code applies to Muscle Group I, which is involved in upward rotation of the scapula and elevation of the arm above shoulder level. The extrinsic muscles of the shoulder girdle include the trapezius, levator scapulae, and serratus magnus. The rating criteria of Diagnostic Code 5301 differ depending on whether the dominant (major) or nondominant (minor) extremity is being evaluated. In the case at hand, the Veteran is left-handed (see February 2010 VA examination report); thus, the Board will apply the rating criteria for the nondominant extremity. Diagnostic Code 5301 assigns a zero percent rating for slight disability of the nondominant extremity. A 10 percent rating is assigned for moderate disability, a 20 percent rating is warranted for moderately severe disability, and a 30 percent rating is appropriate for severe disability. Muscle Group damage is categorized as slight, moderate, moderately severe or severe and evaluated accordingly under 38 C.F.R. § 4.56. In relevant part, 38 C.F.R. § 4.56(c) describes the cardinal signs and symptoms of muscle disability as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. A slight disability of the muscles involves a simple wound of the muscle without debridement or infection. The service records should demonstrate a superficial wound with brief treatment and return to duty. There must have been healing with good functional results and no consistent complaints of cardinal symptoms of muscle injury or painful residuals. The objective findings are a minimum scar, slight, if any, evidence of fascial defect or of atrophy or of impaired tonus, and no significant impairment of function and no retained metallic fragments. A moderate disability of the muscles involves a through-and- through or deep penetrating wound of a relatively short track by a single bullet or small shell or a shrapnel fragment, and the absence of explosive effect of high-velocity missile and of residuals of debridement or of prolonged infection. There must be evidence of in-service treatment of the wound. There must be a record in the file of consistent complaint of one or more of the cardinal symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. The objective findings include entrance and, if present, exit scars which are linear or relatively small, and so situated as to indicate a relatively short track of the missile through the muscle tissue; signs of some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. Slight muscle disability is characterized by no cardinal signs or symptoms of muscle disability as noted above. Objective findings include minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). Moderate muscle disability is characterized by one or more of the cardinal symptoms of muscle wounds, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Relevant objective findings include small or linear entrance and exit scars (if present) indicating short track of missile through muscle tissue. Other findings include some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Board notes that normal shoulder motion is defined as 0 to 180 degrees of forward elevation (flexion), 0 to 180 degrees of abduction, and 0 to 90 degrees of internal and external rotation. See 38 C.F.R. § 4.71, Plate I. The Veteran sustained a shrapnel wound to the right shoulder during service in Vietnam in May 1970. Service connection for residuals of shrapnel wound to the right shoulder was granted in a January 1972 rating decision. An initial noncompensable rating was assigned from March 1971. The Veteran filed his claim for an increased rating in October 2000. The service treatment records do not document the right shoulder injury and the service separation examination in January 1971 noted normal examination of the upper extremities. Initial VA examination in December 1971 found no current residuals of the right shoulder shrapnel wound. X-ray showed a two millimeter metallic density in the soft tissues of the axilla. Service connection was granted in January 1972 based on this X-ray evidence and the Veteran's award of a Purple Heart. A November 1976 VA examination found no abnormality of the right shoulder. There was full free motion of the shoulder. The diagnosis was shrapnel wound right shoulder with residuals of small metallic body in the soft tissues of the axilla. On VA examination in December 2000, the Veteran reported pain and stiffness of the right shoulder. On examination, there was a one centimeter by one centimeter scar on the right scapula. This was non-tender, irregular, pale, depressed, and soft, with no underlying tissue loss, no keloid formation, no disfigurement and no limitation of function. The examiner noted that the involved muscle group did not have any effect on the function of the nearby joints. There was no tendon, bone, joint, or nerve damage, and no muscle herniation. The shoulder was normal in appearance. Shoulder flexion was to 180 degrees, abduction to 180 degrees, and external and internal rotation were each to 90 degrees. No pain was associated with any of the ranges of motion. Right shoulder x-ray showed degenerative changes at the acromioclavicular joint with a small spur at the region of the acromion. With regard to effects on occupation and activity, the examiner sated that during episodes of pain in the right shoulder, he would have difficulty in reaching for objects above head level, or limited used of the right arm. Writing, grasping, grabbing, and fingering were not affected. He was currently able to work full time. An October 2001 private record, following rehabilitation from his February 2001 injuries sustained in a motor vehicle accident, reflects 5/5 strength in all extremities but for the left upper extremity. It was assessed that he had good recovery but had neuropathic pain. He was referred to vocational services to assess whether he met the job requirements to return to work. At his August 2004 hearing before the Board, the Veteran stated that occasionally his arm would be weak and hurt. His arm and hand would feel numb sometimes. On January 2006 VA examination, physical examination of the shoulder showed scarring on the left, otherwise there was no asymmetry. Flexion of the shoulder was normal. The assessment was a small shrapnel wound with some chronic pain in the right shoulder. On VA examination in February 2010, the Veteran reported intermittent right shoulder pain. The examiner noted that muscle strength tests for all muscle groups in the upper extremities were symmetric and normal, 5/5. Muscle tone was normal with no atrophy. Examination showed no deformity, giving way, instability, stiffness, weakness, incoordination, locking, dislocation, or effusion of the right shoulder. There was no effect on the motion of the joint caused by the shrapnel wound. There was a small, well-healed, superficial scar at the posterior shoulder, measured as 0.2 centimeter by 0.8 centimeter. Flexion was from zero to 180 degrees; extension from zero to 180 degrees; internal rotation from zero to 80 degrees; and external rotation from zero to 180 degrees. There was no objective evidence of pain with active motion or following repetitive motion, and no additional limitations following repetition. X-rays showed mild to moderate degenerative joint disease of the right shoulder. The diagnosis was well-healed shrapnel wound scar of right shoulder; degenerative joint disease of right shoulder most likely age-related. The examiner stated that the residuals of right shoulder shrapnel wound had no significant effects on the Veteran's usual occupation and no effects on his daily activities. On January 2013 VA examination, it was found that there were two scars on the posterior scapular area that were well-healed, superficial, and barely visible. The scars were linear and measured .2 by .5 centimeters and .2 by .4 centimeters. Considering the Veteran's wound residuals under the criteria for muscle injury, his documented symptomatology is not more than slight and does not warrant a compensable evaluation under Diagnostic Codes 5301. See 38 C.F.R. § 4.73. The medical evidence does not support a conclusion of more than a slight injury to muscle group I. Here, the Veteran has a retained fragment and has had problems with intermittent shoulder pain, but experiences no functional debility in terms of muscle strength or action. Examiners have specifically noted that there was no loss of muscle function. There has been no loss of deep fascia or muscle substance or impairment in tonus. Rather, the findings made on examinations have correlated well with the expected findings for the definition of slight muscle impairment. There is no fascial defect, no muscle atrophy and, as already noted, no loss of function. Although he has a retained fragment with intermittent pain, his disability picture approximates the criteria for "slight" impairment. 38 C.F.R. § 4.7. Indeed, his disability exactly mirrors the criteria for a characterization of "slight" impairment except for the small retained fragment and complaint of pain. Even with the complaint of pain and the episodes described by the Veteran, there has been no demonstration of loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, or uncertainty of movement. As already noted, his muscle functions without impairment. Muscle impairment is therefore best characterized as no more than "slight." In Tropf v. Nicholson, 20 Vet. App. 317 (2006), the Court addressed the question of whether an appellant who has retained metallic fragments in the muscle, but is essentially asymptomatic, is entitled to a compensable disability rating under 38 C.F.R. § 4.56 and DC 5303 for a "moderate" disability of the muscle, given that section 4.56(d)(1)(iii) indicates that a "slight" disability rating will not be assigned where there are metallic fragments retained in muscle tissue. In answering this question in the negative, the Court determined that section 4.56(d) contains a totality-of-the-circumstances test in which no single factor is per se controlling for rating purposes, but rather are merely "factors to be considered" in assigning the appropriate rating. Thus, even though there may be retained metallic fragments in the muscle of his right upper arm, the appellant was not entitled to a compensable rating as a matter of law. Alternatively, the medical evidence of record does not support a compensable rating for limitation of motion of the right arm. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. In order to qualify for a compensable rating under Diagnostic Code 5201, the evidence must indicate that the Veteran cannot raise his right arm to shoulder level. The evidence shows that the Veteran has full flexion and abduction of the right arm to 180 degrees as noted on the December 2000 and February 2010 VA examinations. These examiners noted that no pain was associated with the Veteran's range of shoulder motion. There is no evidence of additional disability due to weakness, fatigue, or incoordination. Therefore, a compensable rating under Diagnostic Code 5201 is not warranted. See 38 C.F.R. § 4.71a. Nor is a rating warranted for the documented arthritis of the shoulder, as that condition has not be diagnosed as a residual of the service-connected shrapnel wound to the right shoulder, but rather has been associated with age. Finally, consideration of DeLuca v. Brown, 8 Vet. App. 202 (1995) is not warranted because the injury has not been shown to affect the joint. Turning to the shrapnel wound scar, the Board notes that by regulatory amendment, the regulations pertaining to skin disabilities, and scars, were amended in 2002 and 2008. The Board will rate the Veteran's claim under both the new and old criteria. The Board finds that, under the old criteria, Diagnostic Codes 7802, 7803, 7804, and 7805, are applicable to the Veteran's claim, and under the new criteria, Diagnostic Codes 7802, 7804, and 7805, are applicable to the Veteran's claim, because those criteria contemplate scars other than of the head, face, or neck. The scars have not been described as deep, nonlinear, or limiting motion such that 7801, old and new, does not apply. Under the criteria in effect prior to 2002 and 2008, Diagnostic Code 7802 provides for a 10 percent rating for a scar other than on the head, face, or neck, that is superficial and that does not cause limitation of motion and measures an area or areas of 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2002 & 2008). Under the criteria in effect since 2008, Diagnostic Code 7802 provides for a 10 percent rating for a scar other than on the head, face, or neck, that is superficial and nonlinear and measures an area or areas of 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2012). Under the criteria in effect prior to 2002 and 2008, Diagnostic Code 7803 provides for a maximum 10 percent rating when there are superficial, unstable scars. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2002 & 2008). Under the criteria in effect prior to 2002 and 2008, Diagnostic Code 7804 provides for a 10 percent rating for superficial scars that are painful on examination. 38 C.F.R. § 4.118 , Diagnostic Code 7804. Under the criteria in effect since 2008, Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful. A 20 percent evaluation is warranted for three or four scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2012). If one or more scars are both unstable and painful, 10 percent will be added to the evaluation that is based on the total number of unstable or painful scars. See Note (2). Under the criteria in effect prior to 2002 and 2008, Diagnostic Code 7805 provides for scars, other, to be rated based upon limitation of motion of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2002 & 2008). Under the criteria in effect since 2008, Diagnostic Code 7805 provides for other scars to be evaluated by any disabling effects not considered in a rating provided under codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2012). In order to warrant a higher rating under the prior criteria, the Veteran would have to have third degree burn scars under Diagnostic Code 7801. 38 C.F.R. § 4.118 (2002). However, the Veteran's scar is not the result of a third degree burn. Additionally, there is no indication that the Veteran's scar is poorly nourished or ulcerated. Accordingly, the only other rating for consideration is an evaluation of limitation of function of the part affected under Diagnostic Code 7805. However, there is no objective evidence of record to show that the Veteran suffers from any limitation of function. The VA examiners found that the muscle mass and strength were normal and that there was no limitation of function. The scar has not changed in appearance over the years. Moreover, there is no objective evidence of any pain caused by the scar and no nerve involvement. The Board therefore finds that the evidence of record does not support a finding that there is a functional limitation resulting from the Veteran's right shoulder shrapnel wound scar that would warrant a compensable rating. Finally, there is no competent evidence to show that the Veteran's right shoulder scar is productive of an area or areas exceeding 6 square inches (38.7 cm. squared), is superficial and poorly nourished, with repeated ulceration, is tender and painful on objective demonstration, or is unstable. Thus, the assignment of a compensable evaluation for the Veteran's residuals of right shoulder shrapnel wound is not warranted under the relevant criteria based on either muscle damage, limitation of motion, or scarring, and the claim must be denied. III. Other Considerations The Board has considered whether a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected disability. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD and shrapnel wounds to the head and right shoulder with the established criteria found in the rating schedule. The discussion above reflects that the symptoms of the Veteran's PTSD and shrapnel wounds to the head and right shoulder are contemplated by the applicable rating criteria. There are higher ratings available under the diagnostic code for PTSD and shrapnel wounds to the head and right shoulder, but the Veteran's symptoms are not productive of the manifestations that would warrant the higher rating. The effects of the Veteran's disabilities have been fully considered and are contemplated in the rating schedule. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2012). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides a rating of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (2012). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15 (2012). All veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. Indeed, a total rating based on individual unemployability may be assigned in the case of a Veteran who fails to meet the percentage requirements but who is unemployable solely by reason of service-connected disability on an extraschedular basis. 38 C.F.R. § 4.16(b). In order to meet this standard, the record must show some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, the Board finds that at no time during the pendency of the appeal has a TDIU been warranted. In addition to the evidence summarized in the preceding decision, an August 2003 Social Security Administration assessment reflects a finding that the Veteran was unable to work in a stressful situation. He was unable to use his upper extremities due to severe weakness. A corresponding outpatient treatment record by the same physician noted some mild cognitive problems and difficulty with memory and fatigue related to his traumatic brain injury. At his August 2004 hearing before the Board, the Veteran stated that following his traumatic brain injury, he believed he could return to work to at least answer telephones, but was told that he could not handle any stressful situations. In February 2011, a VA examiner reviewed the Veteran's claims file and determined that it was less likely than not that the Veteran's service-connected psychiatric disorder created a barrier or impairment that prevented gainful, sedentary or occupational experience. A review of the file showed that at the time of the motor vehicle accident, the Veteran denied any pre-existing psychiatric history or mental health problems. Rehabilitation records related to the accident showed no PTSD symptoms. He was shown to have a mild cognitive impairment only. The GAF scores on previous VA examinations were taken into account, as well as that there was no indication of current cognitive impairment due to the in-service head injury. The examiner concluded that the Veteran's psychiatric symptoms were in the moderate range. Rather, it seemed that his motor vehicle accident was the primary reason that he did not return to work, rather than an inability to work due to his PTSD. In February 2011, a VA examiner reviewed the Veteran's claims file and determined that the Veteran's right shoulder did not preclude employment, as the records dated since 1971 showed full range of motion of the shoulder and were silent for treatment-related complaints due to pain and discomfort. The records also did not show complaints related to the shrapnel wound to the head. Any cognitive impairment was due to the motor vehicle accident and not due to the service-connected head injury. The examiner therefore determined that it was less likely than not that the combined effects of the Veteran's service-connected disabilities would together prevent him from obtaining or maintaining gainful employment for which his education and occupational experience would otherwise qualify him. On January 2013 VA psychiatric examination, the examiner determined that the Veteran's ability to understand and follow directions was considered not impaired. The Veteran's ability to retain instructions as well as sustain concentration to perform simple tasks was considered not impaired. His ability to sustain concentration to task persistence and pace was considered to be mildly impaired. His ability to respond appropriately to coworkers, supervisors, and the general public was considered to be moderately impaired. His ability to respond to changes in the work setting was moderately impaired. From a mental health perspective, alone, the Veteran's PTSD and shrapnel injury to the head did not render him unable to secure or follow a substantially gainful occupation. That opinion was based on the Veteran's work history, which included retiring from the same position having served on two labor unions. In this case, despite the Veteran's claim that his service-connected disabilities, particularly his PTSD, preclude employment, the Board finds that the evidence weighs against that contention. Repeated VA examinations as to the specific issue of entitlement to a TDIU have concluded that the Veteran's service-connected disabilities alone do not preclude employment. Although the lone 2006 VA psychiatric examination was supportive to the Veteran's claim, as stated above, it has since been discounted because of its subjective, nonclinical nature. Moreover, the 2006 opinion did not state that the Veteran's PTSD precluded employment. The other opinions on the matter, both before and after the 2006 opinion, are against the Veteran's claim. Thus, on the issue of whether the Veteran would be unable to obtain and maintain gainful employment solely because of his service-connected disabilities, the opinions in this case have been consistently against such a finding. In view of the foregoing, the Board finds that the preponderance of the evidence does not show that the Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment. The Board concludes that the evidence does not demonstrate that the Veteran's service-connected disabilities alone, when considered in association with his educational attainment and occupational background, renders him unable to secure or follow a substantially gainful occupation. As such, entitlement to a TDIU must be denied. Furthermore, in the absence of any evidence of unusual or exceptional circumstances beyond that that contemplated by the assigned scheduler disability evaluations, a referral for consideration of a TDIU on an extraschedular basis is not warranted, and the preponderance of the evidence is against the claim. Therefore, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). ORDER For the period prior to January 29, 2013, an increased 50 percent rating for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. Since January 29, 2013, a rating in excess of 70 percent rating for PTSD is denied. A rating in excess of 10 percent for the residuals of shrapnel wound to the head is denied. A compensable rating for residuals of shrapnel wound to the right shoulder is denied. A TDIU is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs