Citation Nr: 1322234 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 10-21 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to increased rating for the service-connected depressive disorder, rated as 50 percent disabling prior to April 20, 2011, and as 70 percent disabling from that date. 2. Entitlement to rating in excess of 10 percent for the service-connected left knee strain. 3. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for chronic residuals of a left shoulder injury. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from June 2000 to December 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas that continued current ratings of 50 percent for the service-connected depressive disorder and 10 percent for the service-connected left knee disability, and also denied compensation under 38 U.S.C.A. § 1151 for residuals of injuries of the ribs and left shoulder. In his substantive appeal, received in May 2010, the Veteran requested a hearing before the Board, but in July 2010 he submitted a written statement withdrawing his request for a hearing before the Board and requesting a hearing before the RO's Decision Review Officer (DRO) instead. A DRO hearing was duly scheduled in April 2011, but prior to the hearing the Veteran submitted a Statement in Support of Claim requesting the DRO hearing be cancelled. The claim was remanded by the Board in May 2012. In December 2012 the Agency of Original Jurisdiction issued a rating decision that increased the rating for the depressive disorder to 70 percent effective from April 20, 2011. The same rating decision granted a separate 20 percent rating for instability associated with the service-connected left knee disability, effective from April 20, 2011. Finally, the December 2012 rating decision granted compensation under 38 U.S.C.A. § 1151 for myofascial syndrome of the left thoracic back, representing a complete grant of compensation for a "rib injury" on appeal. During VA mental health examination in April 2011 the Veteran asserted he is unemployable due to his service-connected right wrist and left knee disabilities. Thus, the file raises an informal claim for total disability rating based on individual unemployability due to service-connected disabilities (TDIU). The Agency of Original Jurisdiction has not adjudicated this issue, so it is not before the Board. The issue of entitlement to TDIU is accordingly referred to the Agency of Original Jurisdiction for appropriate action. FINDINGS OF FACT 1. Prior to May 20, 2009, the disability picture associated with the Veteran's major depressive disorder more closely approximated occupational and social impairment with reduced reliability and productivity. 2. From May 20, 2009, the disability picture associated with the Veteran's major depressive disorder has more closely approximated occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 3. The Veteran's chronic left knee strain is manifested by normal extension and flexion to 90 degrees or better, with pain; there is no clinical evidence of instability prior to April 20, 2011. 4. The Veteran does not have chronic residuals of injury to the left shoulder that are proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical treatment, or by an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for a rating for depressive disorder of 70 percent, but not more, were met effective from May 20, 2009, but not before. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.130, Diagnostic Code 9434 (2012). 2. The criteria for a rating higher than 10 percent for chronic left knee strain are not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261 (2012). 3. The criteria for compensation under 38 U.S.C.A. § 1151 for a chronic left shoulder disorder are not met. 38 U.S.C.A. §§ 1151, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Before addressing the merits of the Veteran's claims on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Veteran was notified of the elements required to show entitlement to a higher disability rating and the elements to show entitlement to compensation under 38 U.S.C.A. § 1151 by a letter in April 2009, and he had ample opportunity to respond prior to issuance of the July 2009 rating decision on appeal. In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See 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 an error is harmful or prejudicial normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran's service treatment records and service personnel records are associated with the claims file, as are post-service treatment records from those VA and private medical providers the Veteran has identified as having records potentially relevant to adjudication of the issues on appeal. The Veteran withdrew his request for hearings before the RO's DRO and before the Board. The Veteran has also been afforded appropriate VA examinations in regard to the issues on appeal. In specific regard to the issue of entitlement to compensation under 38 U.S.C.A. § 1151, the Board remanded the file for medical examination and opinion, which was provided in July 2012; the Board has reviewed the examination report and finds the Agency of Original Jurisdiction substantially complied with the requirements articulated in the Board's remand instructions. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran was also provided VA examinations relating to the rating issues on appeal (joints examination and mental examination) in April 2011; the Veteran has not asserted, and the evidence of record does not show, that his symptoms have changed significantly since those examinations. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Evaluation of Disabilities Applicable legal principles Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. In any claim for higher ratings, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Evidentiary considerations In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, id. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities herein decided. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of remote clinical histories and findings pertaining to the disabilities. The instant claim for increased rating was received in February 2009. The Board will consider evidence of severity of symptoms since February 2008. See 38 C.F.R. § 3.400. Schedular evaluation of major depressive disorder Major depressive disorder is rated under the criteria of 38 C.F.R. § 4.130 (schedule of ratings - mental disorders), diagnostic code 9434 (major depressive disorder). In relevant part, the rating criteria are as follows. A rating of 50 percent is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A rating of 70 percent is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A rating of 100 percent is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behaviour; 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. The Veteran had a VA mental disorders compensation and pension (C&P) examination in December 2007, performed by a psychologist who interviewed the Veteran and administered a battery of tests. The Veteran reported being apathetic and unmotivated, with problems concentrating. He endorsed irritability, anger and occasional suicidal ideation, although he denied current suicidal ideation. He reported that he cried all the time and had decreased appetite. These symptoms were fairly constant. The Veteran was currently employed in a restaurant and had not had any reprimands, but he did not feel motivated to go to work and thus had loss of income from not working shifts. The Veteran currently worked part-time and attended school part-time; he felt his school performance had declined recently due to increased depression. He endorsed being able to perform activities of daily living (ADLs) without impairment but had no social involvement and no leisure interest other than sleeping. He complained of short-term memory impairment but stated the long-term memory was fair. The examiner characterized the Veteran's self-reported symptoms as depressed mood with associated crying spells, anhedonia, reduced appetite, fatigue, feelings of guilt and worthlessness, and observed psychomotor slowing and difficulty with concentration. Associated with the depression and personality disorder was reported anger and irritability with a history of physical aggression. During the December 2007 C&P examination, mental status evaluation (MSE) showed the Veteran to be adequately groomed. He had flattened affect and some evidence of psychomotor slowing. Thought process was logical, coherent and relevant. Affect was depressed. The Veteran was well oriented times four. Reasoning and judgment were fair-to-poor. The examiner diagnosed major depressive disorder (MDD), recurrent and moderate (Axis I), as well as personality disorder not otherwise specified (NOS) with antisocial and paranoid traits (Axis II). The examiner assigned a global assessment of functioning (GAF) of 55. The Veteran received VA inpatient psychiatric treatment in February and March 2009 due to reported suicidal ideation. When he attempted to elope from the mental health clinic he was restrained by VA police and sedation was administered. The discharge summary shows that at time of admission the Veteran had very depressed mood, flat affect and suicidal ideation; he also had a very negative outlook and feeling of hopelessness. At time of discharge the Veteran had no psychomotor agitation or retardation; mood was good with reactive and euthymic affect; thought process was organized and goal-oriented; though content had no suicidal or homicidal ideation, no hallucinations and no delusions; insight was fair, and judgment was good. The diagnosis was depressive disorder NOS. The Veteran was assigned a GAF of 25 at the time of admission and GAF of 55 at discharge. Outpatient therapy notes in March 2009 show the Veteran reported feeling better after inpatient treatment. The Veteran denied being depressed or suicidal; he was sleeping better and had a more positive outlook. The Veteran reported he was still attending school and still working. Treatment notes for the month generally show the Veteran was socializing and attending events out of the house; he endorsed some suicidal ideation but denied intent. The Veteran had a VA C&P examination by a psychologist April 2009, during which he reported he was still in college but was about to drop out because his psychotropic medications made it hard to concentrate. The Veteran admitted a history of verbal aggression but denied assaultive behavior, and he reported one suicide attempt. He admitted suicidal ideation and having made homicidal threats. He endorsed anger, lack of motivation, excessive sleep and frequent crying; he also endorsed nightmares. The Veteran stated he was able to perform ADLs without impairment. His leisure activities had included improving his education, but he had to drop the course because of lack of concentration. Review of symptoms (ROS) resulted in the Veteran endorsing anxiety, panic and depression. The Veteran endorsed hypersomnia and stated he would vegetate in his home for four days at a time with very little social contact or grooming. He denied appetite problems but endorsed crying spells, anhedonia and nightmares. He also endorsed obsessional ideation such as repeatedly washing his car. He endorsed racing thoughts, head pain, some gastric problems, procrastination and unfinished projects. He reported anger control problems and homicidal threats toward his ex-wife, her boyfriend, and two of his co-workers. He denied hallucinations, delusions or paranoia but endorsed both homicidal and suicidal ideas. During the April 2009 C&P examination, the Veteran acted as though he believed himself to be totally incapacitated by his marital and familial problems; his thought process was illogical but not psychotic. He was well-groomed and oriented times four, and reasoning was good, but his affect was flat and blunted. There was no indication of psychomotor slowing or agitation. Verbal comprehension and concentration were both good, but he complained of short-term memory problems including difficulty recalling names and having to make lists to remind himself what to do. Sensorium was cloudy. During psychological testing the Veteran produced extremely exaggerated responses, indicating histrionic tendencies and mood instability. The examiner diagnosed mood disorder NOS and cannabis abuse (Axis I) and also diagnosed personality disorder NOS with borderline narcissistic and antisocial features (Axis II). The examiner assigned a GAF of 55. The C&P examiner in April 2009 stated the Veteran appeared to be over-reacting to a number of situational factors and had illogically developed the idea that his violent behavior was justified by his inability to visit his son. The examiner stated that the Axis II diagnosis (personality disorder) played a very strong role in the Veteran's condition in that a large portion of his problems had to do with overall immaturity and under-developed personality as diagnosed in Axis II. The examiner specifically stated the Veteran's condition was not worse than his current disability rating. Outpatient treatment records in April 2009 show the Veteran reported having quit school due to problems with concentration; however, he stated this was temporary and was done in order to prevent negatively impacting his grade point average. He continued to complain about being prevented from seeing his son. The Veteran was given a clinical examination by a VA psychologist in May 2009 during which he reported feeling very depressed. He reported having dropped out of online college courses due to difficulties with attention span and lack of motivation. He endorsed daily homicidal and suicidal ideation but denied intent; he stated he had not acted on his ideation because he had made a promise to his VA counselor. His primary current complaint was difficulty with attention and concentration. He admitted to anhedonia, low energy levels, decreased appetite and poor sleep; he denied symptoms of mania. He reported being depressed on a level of 8/10, with mood-congruent affect. Veteran was appropriately groomed and oriented times four. Speech was normal in rate but moderately monotone and low in volume. There was no indication of hallucinations or delusions. Thought content appeared to be illogical but not in a psychotic sense. The Veteran endorsed being independent in ADLs. The psychologist diagnosed depressive disorder NOS and dysthymic disorder (Axis I) and also diagnosed personality disorder NOS with prominent features of borderline schizoid and dependent (Axis II). The psychologist assigned a current GAF of 35. The psychologist stated the Veteran appeared to be suffering from chronic depression with current significant emotional distress and feeling of insecurity and hopelessness causing him to view the world bleakly. The Veteran had repeatedly verbalized suicidal ideation and had made one previous suicide attempt; he also had an extensive history of hospitalization for suicidal threats; test data indicated the Veteran may have difficulty regulating his emotions, and he appeared to react to feelings of depression by thinking about suicide. This tendency could be due to limited cognitive ability to consider alternative for coping with depressed mood. The psychologist in May 2009 also stated the Veteran appeared to have significant difficulties related to interpersonal functioning, vacillating between dependent behavior and avoidant behavior. This could pose a danger to individuals such as treatment providers who could serve as objects of dependence. In addition to these mood and interpersonal relationship problems, the Veteran tended to externalize blame and viewed the world in a negative and hostile manner; his view of the world was not based on reality and appeared illogical in nature. During VA outpatient treatment in June 2009 the Veteran expressed dismay that his VA counselor would soon be leaving her position to pursue a position elsewhere. In July 2009 he reported he was still working but had almost quit during the previous week because of conflict with his employer. In August 2009 VA outpatient treatment the Veteran was upset about having been denied increased VA benefits and also distressed about visitation issues regarding his son. MSE showed the Veteran to be alert and fully oriented and well-groomed. His speech was monotone and his mood was "upset." His affect was blunted and tearful when talking about his therapist leaving. Thought process showed rumination and perseverance about the end of therapy. No psychotic symptoms were elicited. The Veteran was not actively suicidal or homicidal. Insight was poor. The clinician noted there was a significant component of Axis II (personality disorder) involved, which complicated his clinical presentation when facing the loss of his therapist. Later in August 2009 the Veteran was observed on several instances to be crying during VA outpatient therapy and unable to complete assigned tasks. The Veteran denied being suicidal but stated he was feeling hopeless. In October 2010 the Veteran presented to his VA attending psychiatrist and admitted he had not been compliant with medications. The psychiatrist noted the Veteran had been struggling with abandonment and rejection issues and using splitting and projection, which was typical for his personality structure. The Veteran reported chronic feelings of emptiness, dysphoric mood, hopelessness and depression. He denied active suicidal ideation or intent. The Veteran declined further therapy and left the office. The Veteran had a VA C&P examination in April 2011, performed by a psychologist who reviewed the claims file. The Veteran reported having had at least 15-20 acute hospitalizations for suicidal ideation or gesture. The Veteran complained of financial problems, of inability to speak to or visit his son and of being forced to attend therapy at VA. The Veteran admitted he was not taking medication because he considered it to have been ineffective in the past. He described feeling of abandonment when his VA therapist departed; he also complained of having been beaten by VA police in 2007. The Veteran complained of depressed mood, anger, chronic pain, difficulty with trust, frustration, discouragement with his life circumstances, sleep disturbance with bad dreams, worthlessness, tiredness and fatigue, reduced appetite and regular crying spells. The Veteran was currently unemployed and not attending school. He described having no close friends and essentially remaining by himself. The Veteran denied panic attacks. He complained of short-term memory and concentration issues and of periods of psychomotor retardation. He reported reduced appetite, low self-esteem and restlessness. He reported problems with anger, verbal aggression and threatening behavior and regular suicidal ideation without plan or intent; he had also demonstrated homicidal gestures in the past but denied imminent homicidal ideation. He denied obsessive-compulsive or ritualistic behavior that interfered with routine activities. MSE in April 2011 showed the Veteran to be oriented times four. He was adequately groomed; his ability to perform personal hygiene and minimal ADLs did not appear to be significantly impaired by his mental health symptoms. His speech was mumbling but coherent. The Veteran had poor social skills during interview and presented as guarded, pessimistic and tearful. There was no evidence of marked psychomotor activity. Mood was depressed, with blunted affect. No delusions, hallucinations or other perceptual disturbances were elicited or reported. Thought processes were clear and coherent; thought content was preoccupied with his dire life circumstances including separation from his son and related feelings of hopelessness. Insight and judgment were limited. The examiner diagnosed MDD, recurrent, chronic and severe, without psychotic features, and cannabis abuse (Axis I) and also diagnosed personality disorder NOS with borderline, schizoid and dependent personality disorder features (Axis II). The examiner assigned a current GAF of 43, noting most recent clinical GAF score of 44 (March 2010). The examiner in April 2011 stated the Veteran's recent therapy termination appeared to have induced feelings of rejection and abandonment related to his complex personality structure; this suggests that a large portion of the Veteran's psychiatric difficulties are likely more driven by his entrenched personality patterns than Axis I pathology. The Veteran had difficulty regulating his mood and felt empty, hopeless and pessimistic about any responsibility for relief of his symptoms. The Veteran's prognosis was guarded without long-term therapy and treatment, but the Veteran had been non-compliant with treatment in the past and cynical about resuming treatment in the future. The Veteran had no close friends and his social support was very much limited, but his routine responsibilities of self-care and ability to perform ADLs were not significantly impaired secondary to mental health problems. In sum, there was reduced reliability and productivity due to mental disorder signs and symptoms. Review of the evidence shows that during the period February 2008 to May 2009 the Veteran's disability picture more closely approximated the criteria for the currently-assigned 50 percent rating. The Veteran was employed and was also attending school. He had one instance of suicidal ideation resulting in hospitalization (in February 2009) but after discharge he denied ideation or intent and professed he felt himself to improved; "suicide ideation" is the only symptom associated with the higher 70 percent rating that was documented during the period.. The Veteran complained during the period of difficulty concentrating and memory impairment, but this is squarely within the criteria for the 50-percent rating, are his documented disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. Significantly, the VA examiner in April 2009 stated an opinion that the Veteran's condition was not worse than his current disability rating. The Board accordingly finds that prior to May 2009 the Veteran did not show occupational and social impairment with deficiencies in most areas, as required for the higher 70 percent rating. The report of the VA psychologist on May 20, 2009, documents a decline in occupational and social functioning warranting an increased rating. The psychologist documented deficiencies in school, family relations, judgment, thinking and mood, with increasing functional impairment due to suicidal ideation. Significantly, the psychologist stated that the Veteran posed a potential threat to care-givers, although she did not suggest he posed an imminent threat to himself or others. There is no indication of any significant improvement of these symptoms between May 2009 and April 2011, the currently-assigned effective date for the 70 percent rating. The Board has considered the GAF ratings assigned during the period under review. The GAF records the clinician's judgment of the individual's overall level of functioning, with 100 representing a high level of functioning and no psychiatric symptoms. See Quick Reference to the Diagnostic Criteria from DSM-IV, Washington, D.C., American Psychiatric Association, 1995. While the GAF is not the sole basis for assigning a disability rating, it provides a clinical indicator of the patient's functional ability. There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Prior to May 2009 the Veteran consistently had a GAF of 55 (examination in December 2007, inpatient discharge in February 2009 and examination in April 2009); the sole exception was at the time of inpatient admission in February 2009. GAF scores between 51 and 60 indicate moderate symptoms or moderate difficulty functioning. Quick Reference, supra, pg. 46-47. Thereafter, the VA psychologist in May 2009 recorded a GAF of 35, rising to 44 in March 2010 (VA clinic) and 43 in April 2011 (VA examination). GAF scores between 31 and 40 indicate some impairment in reality testing or communication or major impairment in several areas, while GAF scores between 41 and 50 indicate serious symptoms or any serious impairment in social, occupational or school functioning. Id. Thus, the GAF scores during the period are consistent with disability rating of 50 percent prior to May 2009 and 70 percent thereafter. The Board has considered whether a rating higher than 70 percent is warranted. However, none of the symptoms associated in the rating schedule with the 100 percent rating are shown. The Veteran is affirmatively shown to be able to perform ADLs and has been consistently shown on examination to be oriented and able to express himself. There is no indication of gross impairment in thought processes or grossly inappropriate behaviour, and at no point during the period under review has the Veteran been considered to be a persistent danger of hurting himself or others. The Board recognizes that multiple examiners have expressed an opinion that the Veteran's overall psychiatric disability is caused in great part by his nonservice-connected personality disorder rather than his service-connected MDD. However, the Board is precluded from differentiating between the symptomology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). In sum, the Board accordingly finds the Veteran's disability picture more closely approximates the criteria for a 70 percent rating, but not more, effective from May 20, 2009, but not before. Because the criteria for higher ratings were not shown during any distinct period, a "staged rating" is not warranted. Hart, 21 Vet. App. 505. Reasonable doubt has been resolved in favor of the Veteran. Gilbert, 1 Vet. App. 49, 54. Schedular evaluation of left knee disability When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.59 cited above are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Limitation of flexion of a leg warrants a noncompensable evaluation if flexion is limited to 60 degrees, a 10 percent evaluation if flexion is limited to 45 degrees, a 20 percent evaluation if flexion is limited to 30 degrees or a 30 percent evaluation if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5260. Limitation of extension of a leg warrants a noncompensable evaluation if extension is limited to 5 degrees, a 10 percent evaluation if extension is limited to 10 degrees, a 20 percent evaluation if extension is limited to 15 degrees, a 30 percent evaluation if extension is limited to 20 degrees, a 40 percent evaluation if extension is limited to 30 degrees or a 50 percent evaluation if extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Normal range of motion (ROM) of the knee is extension to 0 degrees and flexion to 140 degrees. 38 C.F.R. § 4.71a, Plate II. The VA General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 17, 2004). The Veteran had a VA C&P examination of the joints in December 2007. The examiner noted that recent magnetic resonance imaging (MRI) had shown questionable tear in the medial meniscus and posttraumatic change in the medial femoral condoyle; recent X-ray of the left knee had been normal. The Veteran denied periods of flare-up. The Veteran was observed to wear a knee brace. The Veteran reported having to occasionally miss work (as a server in a restaurant) due to pain in the wrist and knee; he stated the wrist and knee caused impairment of ADLs in that he had trouble carrying heavy items and had occasionally had the knee give way. Examination showed the Veteran to have normal gait. ROM of the knee was 0 to 100 degrees. There was tenderness over the medial femoral condoyle. There was no effusion, no varus or valgus instability and negative Lachman's. There were no additional functional limitations after repetitive use other than increased pain. There was no effect of incoordination, fatigue, weakness or lack of endurance. The examiner's diagnosis was chronic left knee sprain. The Veteran had another VA C&P joints examination in April 2009, performed by an examiner who reviewed the claims file. The Veteran complained that his chronic left knee pain essentially bothered him all the time. He reported intermittent swelling and giving way, but denied locking. He was noted to wear a knee brace, which the Veteran stated provided some relief of instability. The Veteran endorsed increased knee pain when walking and also with standing at work and also endorsed giving way when the knee became tired. The Veteran stated he could walk at most one-quarter mile and could stand for at most 15-20 minutes. The Veteran stated he experienced increased knee pain at work because of the requisite standing and walking. He only worked 3-4 hours at a time. The Veteran endorsed increased limitation with repetitive use of the knee. Pain medication provided some relief, as did his cane, but he was unable to use the cane at work. On examination the Veteran used a cane but did not have a limp. There was generalized tenderness to all areas of the knee. ROM was 0-140 degrees; repetitive motion resulted in complaint of increased tenderness but there was no demonstrated loss of motion, weakness, fatigability or incoordination. The knee was clinically stable to varus/valgus stress, anterior drawer and Lachman's tests. The examiner noted that previous X-rays of the left knee had been normal. The examiner diagnosed chondromalacia of the left knee. The Veteran was also examined in April 2009 by a VA psychologist, who noted parenthetically that the Veteran presented using a cane and seeming to struggle to walk, but he forgot his cane in the examiner's office and was observed to walk perfectly normally without it. The examiner stated the Veteran appeared to have a strong somatoform factor in his condition. The Veteran presented to the VA orthopedic clinic in May 2009 for follow-up of his left knee condition. He complained of pain and was noted to be using a cane and wearing a brace. Physical examination showed no effusion in either knee, and both knees had full ROM. The left knee had no ligamentous instability and was not tender to palpation. X-ray showed preserved joint space. The clinician noted that physical examination had been benign. The Veteran was advised to forego wearing the brace to promote quadriceps strengthening. The Veteran presented to the VA physical medicine and rehabilitation (PM&R) clinic in June 2009 for evaluation. X-ray was essentially normal. Examination showed pain and weakness of the left knee with hypermobile patella and laxity of the medial and lateral collateral ligaments (MCL and LCL) as well as probable damage to the medial and lateral meniscus. The Veteran's gait was antalgic on the left. The clinical findings were probable laxity of MCM and LCL, chondromalacia patella and damage to the medial and lateral meniscus. The Veteran presented to the VA orthopedic clinic in August 2009 for follow-up. The Veteran endorsed having been to physical therapy for quadriceps strengthening. Examination showed no effusion and full ROM (0-130 degrees). The knee was tender to palpation but stable (stable to varus/valgus and negative Lachman or post-drawer). There was no joint line tenderness. The clinical impression was possible meniscal tear, but MRI did not show current meniscal tears. The Veteran's most recent VA joints examination was performed in April 2011, by a physician who reviewed the claims file. The Veteran complained of daily pain, and also complained of instability that had caused him to fall several times. The Veteran stated he was unable to continue working in a hospital or as a waiter because those jobs required him to be on his feet. He stated he had difficulty doing household chores but was able to drive. The Veteran denied flare-ups since the pain was steady, but he endorsed fatigability and lack of endurance. Examination showed the Veteran to walk slowly with a cane, but he did not limp. There was tenderness on palpation of the joint line but no effusion. ROM was 0-90 degrees, with pain. Ligaments were intact, with negative Lachman and McMurray tests. The Veteran resisted repetitive motion but slow repetitive motion resulted in no change in ROM, coordination, fatigue, endurance or pain level. The examiner's diagnosis was chronic left knee strain, effusion and instability. Review of the file shows the Veteran's ROM has consistently been manifested by extension to 0 degrees (normal) and flexion not worse than 90 degrees, even after consideration of additional functional loss due to repetitive motion. Accordingly, the criteria for compensable rating are not met under DCs 5260 and 5261. Because the Veteran's left knee is painful, compensation is warranted for functional loss due to pain. 38 C.F.R. § 4.59; Burton, 25 Vet. App. 1. Functional loss due to pain is to be rated at the same level as functional loss when flexion is impeded; see Schafrath, at 592. The current 10 percent rating is minimum rating for limitation of flexion of the knee and accordingly represents appropriate compensation for pain. The Veteran has been granted separate compensation for instability of the knee effective from April 2011. The Board has considered whether the Veteran is entitled to separate compensable rating for instability prior to that date. The Veteran consistently complained of instability and falling, and he is shown to have worn a brace for several years. However, clinical records prior to April 2011 show only one indication of instability (PM&R clinic note in June 2009 showing "probable" laxity of MCM and LCL). All other VA examinations during the period (December 2007, April 2009, May 2009 and August 2009) showed the knee to be stable to the appropriate clinical tests. In sum, the Board has found disability picture more closely approximates the criteria for the currently-assigned 10 percent rating. Because the criteria for higher ratings were not shown during any distinct period, a "staged rating" is not warranted. Hart, 21 Vet. App. 505. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Extraschedular evaluation and entitlement to TDIU The Board also has considered whether referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria for MDD and for left knee disability reasonably describe the Veteran's disability levels and symptomatology, and provide higher ratings for disability levels more severe than those shown by the evidence. Thus, his disability picture is contemplated by the Rating Schedule, and ratings under that schedule are therefore adequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. A request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009); see also Roberson v. Principi, 251 F. 3d 1378, 1384 (Fed. Cir. 2001) (holding that once a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability, the 'identify the benefit sought' requirement of 38 C.F.R. § 3.155(a) is met and the VA must consider TDIU). According to VA General Counsel, the question of TDIU entitlement may be considered as a component of an appealed increased rating claim if the TDIU claim is based solely upon the disability or disabilities which are the subject of the increased rating claim. If the veteran asserts entitlement to a TDIU based in whole or in part on other service-connected disabilities which are not the subject of the appealed RO decision, the Board lacks jurisdiction over the TDIU claim except where appellate jurisdiction is assumed in order to grant a benefit, pursuant to 38 C.F.R. 19.13(a). See VAOGCPREC 6-96. VA General Counsel opinions are binding on the Board. See 38 U.S.C.A. § 7104(c) (West 2002); 38 C.F.R. § 14.507 (2007). The Veteran asserted to the VA mental health C&P examiner in April 2011 that he was no longer employed. He stated he had last worked in a restaurant as a server part-time but was unable to continue due to his knee and wrist pain, both of which are service-connected disabilities. The Veteran did not cite the service-connected psychiatric disability on appeal, and his right wrist disability, which he cited as a contributing factor, is not on appeal. As the Veteran has not asserted unemployability due solely to the psychiatric and left knee disabilities on appeal, the Board finds that a claim for TDIU is not raised by the rating issues herein decided. Compensation under 38 U.S.C.A. § 1151 Applicable Legal Principles A veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C.A. § 1701(3)(A), and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. To establish causation, the evidence must show that the hospital care, medical or surgical treatment or examination resulted in the veteran's additional disability or death. Merely showing that a veteran received care, treatment or examination and that the veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuation or natural progress. 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). Evidence and Analysis The Veteran essentially contends he is entitled to compensation for residuals of injury to the left shoulder that he incurred while being restrained by VA Police in November 2007. (His claim for compensation for an injury to the ribs was granted by the Agency of Original Jurisdiction in December 2012 during the course of the current appeal, and is thus no longer before the Board.) VA mental health records include a "crisis note" dated November 6, 2007. The Veteran reported an intention to drive to Wichita Falls, Texas, to see his son despite being estranged from the child's mother. The clinic was aware of a previous instance in which the Veteran had driven to Wichita Falls while armed with a gun, intending to cause harm; in that instance he was deterred because nobody was home when he arrived. The Veteran was known to still have a gun, and he had previously refused to surrender the firearm. The clinicians determined that the Veteran should be hospitalized to preclude harm to others. The Veteran refused to be hospitalized, and VA police were summoned. The Veteran resisted the VA police, and additional police were summoned. The Veteran continued to resist being restrained, and after warning was administered he was subdued with pepper spray. After being subdued the Veteran was taken by wheelchair to the emergency room (ER) for medical clearance prior to being admitted. The corresponding ER note observed pre-existing right wrist and left knee problems, neither of which showed current aggravation (the right wrist had no swelling and had full range of motion; the left knee had no swelling, the Veteran did not limp and his knee brace was intact). The extremities and other musculoskeletal were otherwise normal. The Veteran's eyes were flushed out. The Veteran refused to have blood drawn, and he was admitted for inpatient psychiatric treatment. A mental health attending physician's note, entered approximately five hours after the Veteran was admitted for inpatient treatment, states the Veteran had no physical complaints. On November 7, 2007 (one day after the altercation and inpatient admission) the Veteran was interviewed and stated he had no physical complaints; he was not happy to be on the inpatient ward but he accepted the situation with good grace. The examining physician stated an impression that the Veteran continued to be a danger to himself or to others and should continue in the current level of restriction. Thereafter the Veteran was uncooperative, reclusive and evasive with staff personnel. The Veteran had a mental health physical examination on November 7; he was reluctantly cooperative with the examination. The Veteran's back, trunk and arms were free of lacerations, abrasions and other signs of bleeding but there were numerous smears and spots on his shirt that appeared to be dried blood. Range of motion of the neck was reduced due to complaint of shoulder and neck pain, and the trapezius muscle was tender to palpation. The extremities had full range of motion, except the left knee due to the pain of an old injury. There was no chest wall point tenderness. The impression was status post aggressive/hostile behavior requiring physical restraint, with no gross abnormalities on examination. A mental health treatment note later the same day noted review of symptoms (ROS) significant for knee and wrist pain (both chronic) and for musculoskeletal pectoral, neck and back pain that minimally limited range of motion. A nursing note on November 8, 2007, states the Veteran reported pain of 7/10 severity in the abdomen, generalized muscle pain, lower and upper back, neck and shoulder. He stated the pain had been present for more than 3 months. A treatment note on November 9, 2007, acknowledges the Veteran's complaint of left shoulder pain the day before, but states X-ray showed no acute changes. The reported neck, back, knee and wrist pains had all slightly improved. The attending staff determined the Veteran no longer posed a threat, and he was cleared to be discharged. The Veteran presented to the VA orthopedic clinic on November 20, 2007, for follow-up of his service-connected left knee condition. While there, he complained of pain in the back, shoulder and ribs after having been "beaten up" by police a few weeks earlier. The treatment note is silent in regard to any observed abnormalities of the back, shoulders or ribs. On December 13, 2007, the Veteran complained to his VA psychiatrist of pain in both shoulders since his altercation with VA police the previous month; the psychiatrist advised the Veteran to consult his primary care physician (PCP) about his symptoms. Thereafter on the same day the Veteran presented to his VA PCP complaining of pain in the left shoulder with difficulty elevating the shoulder since being hit by VA policemen because he had refused to be admitted to the psychiatric unit. Examination of the shoulder showed tenderness to pressure on the acromioclavicular (AC) joint with decreased elevation and range of motion, but no swelling or eccymosis. X-ray was grossly normal. The clinical impression was left shoulder arthralgia. In his instant claim, received in February 2009, the Veteran claimed compensation for left rib cage and left shoulder injuries done by VA security personnel on approximately November 6, 2008 [sic]. Review of the file shows the Veteran was again restrained by VA police in an altercation on February 24, 2009. The Board mentions this incident in order to preclude confusion with the earlier incident in November 2007 that is on appeal. The Veteran reported to a VA C&P psychologist in April 2011 that he was assaulted by VA police in 2007 because he had asked to speak to a previous therapist. He reported he had been struck in the ribs with a stick and that his wrist was bent. He also reported being maced while lying on his stomach crying, and that a policeman used a choke hold on him until he lost consciousness. The Veteran asserted a belief that since that incident VA police had been harassing him. The Veteran had a VA examination in July 2012 in which the examiner stated the Veteran had chronic myofascial syndrome of the left thoracic back that was likely due to the incident in 2007 (based on this opinion the Agency of Original Jurisdiction subsequently granted compensation under 38 U.S.C.A. § 1151 for the claimed "rib injury"). However, in regard to the shoulder, the examiner stated the Veteran had no history of a left shoulder condition and no current left shoulder complaints (the Veteran's current complaints related to the left back, not the left shoulder). Examination of the shoulder, including X-ray, revealed no abnormalities. The examiner stated that because no current left shoulder condition was found on examination no opinion could be rendered regarding a relationship between a claimed left shoulder injury and the incident in 2007. Review of the evidence shows the Veteran was restrained by VA police in November 2007. The Veteran thereafter had some acute and transitory pain, as documented the following day, and he was shown to have arthralgia of the shoulder in December 2007, one month after the incident. However, symptom-based diagnoses such as myalgia and arthralgia are not considered to be diagnosed conditions for compensation purposes. VBA All-Stations Letter 98-17 (02/26/98). See also Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (pain alone, without a diagnosed or identifiable underlying condition, does not constitute a disability for which compensation may be granted). The crux of the issue here is whether any additional disability was actually the result of being restrained by VA Police in November 2007. The file shows no indication of left shoulder complaints between December 2007 and July 2012. Also, the July 2012 VA examination report reflects that an examiner found a clinical examination of the shoulder, including X-ray, to reveal no abnormalities. The examiner specifically opined that the Veteran did not have a current left shoulder disorder. Congress specifically limits entitlement to compensation for disease or injury where such cases have resulted in a disability; in the absence of a proof of present disability there can be no claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the present case, the Veteran has not shown an additional disability for which compensation under 38 U.S.C.A. § 1151 can be considered. The Board has considered the Veteran's lay contention that he suffered an additional left shoulder disability due to being restrained by VA Police in November 2007. The Veteran is competent to report having pain in his left shoulder area at or near the time of being restrained by VA police. However, his assertions of having an additional left shoulder disability at present, absent corroboration by objective medical evidence and opinions, are of extremely limited probative value. This is so because such a determination in this particular instance involves a complex medical matter that requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Significantly, the July 2012 VA examiner explained that the symptoms the Veteran experienced were likely due to chronic myofascial syndrome of the left thoracic back. And as noted, the Veteran was granted compensation under 38 U.S.C.A. § 1151 for the additional disability associated with those symptoms (claimed as a "rib injury"). The record does not show that the Veteran has received the requisite formal medical training and accreditation necessary to make medical diagnoses regarding complex medical issues. Accordingly, his lay statements are neither competent nor probative evidence supporting his claim. See Davidson v. Shinseki, 581 F.3d (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. Moreover, even if his assertion of having an additional left shoulder disability was competent, it is outweighed by the opposing competent medical opinion of record (i.e. the July 2012 VA examiner's opinion). As such, the Board finds entitlement to compensation based upon 38 U.S.C.A. § 1151, must be denied. Because the evidence preponderates against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER A rating of 70 percent for major depressive disorder is granted effective from May 20, 2009. A rating in excess of 10 percent for left knee strain is denied. Compensation under the provisions of 38 U.S.C.A. § 1151 for chronic residuals of a left shoulder injury is denied. ____________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs