Citation Nr: 1330545 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 09-20 493 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California THE ISSUES 1. Entitlement to a rating in excess of 10 percent for a shrapnel wound scar of the right foot. 2. Entitlement to an initial rating for post-traumatic stress disorder (PTSD) in excess of 30 percent, prior to March 19, 2013. 3. Entitlement to a rating in excess of 70 percent for PTSD, from March 19, 2013. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from February 1965 to January 1968. This appeal to the Board of Veterans' Appeals (Board) arose from a November 2006 rating decision in which the RO in San Diego, California denied the Veteran's claim for a rating in excess of 10 percent for a shrapnel wound scar of the right foot. The Veteran filed a notice of disagreement in July 2007. The RO issued a statement of the case (SOC) in March 2009. The Veteran filed a substantive appeal (via a VA Form 9, Appeal to Board of Veterans' Appeals) in May 2009. This appeal to the Board also arose from a May 2010 rating decision in which the RO in Los Angeles, California granted service connection and assigned an initial 30 percent rating for PTSD. The Veteran filed a notice of disagreement with respect to the initial rating assigned for PTSD in May 2011 and an SOC addressing this issue was issued in July 2012. An August 2012 statement in lieu of a VA Form 9 perfecting an appeal to the Board with respect to the initial rating for PTSD was filed in August 2012. In a May 2013 rating decision, the LA RO awarded a higher, 70 percent rating for PTSD. Because the Veteran disagreed with the initial rating assigned following the award of service connection for PTSD, the Board has characterized this claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). Moreover, although the RO granted a higher, 70 percent rating for PTSD, effective March 19, 2013, inasmuch as one or more higher ratings for this disability are available before and after that date, and the Veteran is presumed to seek the maximum available benefit for a disability, the Board has recharacterized the appeal regarding evaluation of PTSD as now encompassing both the second and third matters set forth on the title page. Id; AB v. Brown, 6 Vet. App. 35, 38 (1993). Following additional development, supplemental SOCs (SSOCs) addressing the higher rating claims on appeal were completed in May 2013. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each matter herein decided have been accomplished. 2. The shrapnel wound scar of the right foot is tender but is superficial and does not approach 12 square inches or 77 square centimeters in size. 3. Prior to March 19, 2013, the Veteran's PTSD was manifested by sleep disturbance, outbursts of anger, flashbacks, difficulty with concentration, hypervigilance, intrusive recollections of his war experiences, symptoms of panic and feelings of detachment from others; and a dysphoric mood; overall, these symptoms are indicative of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. Since March 19, 2013, the Veteran's PTSD has been manifested primarily by a depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss; impaired judgment; disturbances of motivation or mood; and disorientation to time or place but not gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); or memory loss for names of close relatives, own occupation or own name; collectively since March 19, 2013, the symptoms of PTSD are indicative of no more than occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a shrapnel wound scar of the right foot are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.118, Diagnostic Code (DCs) 7801-7805 (as in effect prior to October 23, 2008). 2. The criteria for an initial rating in excess of 30 percent for PTSD, prior to March 19, 2013, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411 (2013). 3. The criteria for a rating in excess of 70 percent rating for PTSD, from March 19, 2013, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between a Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. In a claim for increase, the VCAA notice requirements include notice to provide, or ask VA to obtain, medical or lay evidence of increased severity and the impact thereof on employment to substantiate the claim; and providing examples of types of medical or lay evidence that may be submitted, or that VA can be asked to obtain, which are relevant to establishing an increased rating. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), affirmed in part by Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (here, the RO) Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. A September 2006 pre-rating letter provided pertinent notice to the Veteran in connection with the claim for an increased rating for a shrapnel wound scar of the right foot. A February 2010 pre-rating letter provided pertinent notice to the Veteran in connection with what was then a claim for service connection for PTSD. These letters indicated what information and evidence was needed to substantiate each claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. These letters also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates. August and December 2008 letters informed the Veteran of applicable criteria for a higher rating for his shrapnel wound scar of the right foot and otherwise complied the requirements of Vazquez-Flores. A thorough listing of the criteria for rating the Veteran's PTSD was provided in the July 2012 SOC (the timing and form of which suffices, in part, for Dingess/Hartman). After the issuance of the cited notice, and opportunity for the Veteran to respond, the May 2013 SSOCs reflect readjudication of the claims for higher ratings. Cf. Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). Notwithstanding the above, to the extent the Veteran may not have been provided with the complete criteria for rating the disabilities at issue in a notice letter, or that the notice letters are otherwise considered inadequate or not timely, on these facts, the absence of such notice is not shown to have prejudiced the Veteran. As explained below, there is no indication that there is any outstanding evidence pertinent to the claims. Also, pertinent notice consistent with Pelegrini and certain requirements of Dingess/Hartman has been provided. Moreover, because both claims for higher ratings are being denied, no other rating, or effective date, is being, or is to be, assigned; hence, there can be no prejudice to the Veteran under the notice requirements of Dingess/Hartman. As for the duty to assist, the RO obtained the Veteran's service treatment records (STRs) and VA treatment records. The Veteran has been provided multiple examinations, most recently in March 2013 with respect to PTSD and April 2013 with respect to shrapnel wound scar of the right foot. The adequacy of the VA examinations that have been provided has not been challenged. Further, the Veteran was provided an opportunity to testify in support of his claims, and did so, before a Decision Review Officer in May 2012. That hearing appears to have met the requirements of 38 U.S.C.A. § 3.103 (2012); the adequacy of the hearing provided likewise has not been challenged. The Board finds that no additional RO action to further develop the record in connection with any claim on appeal, prior to appellate consideration, is required. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate these claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield, supra, (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. See also 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as with respect to for higher ratings for PTSD, the questions for consideration are entitlement to the matters of higher initial and subsequent ratings assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the award and consideration of the appropriateness of "staged ratings" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. As the RO has already awarded staged ratings for PTSD, the Board will consider the propriety of the rating at each stage, as well as whether any further staged rating is warranted. With respect to the claim for an increased rating for a shrapnel wound scar of the right foot, although the appeal does not stem from disagreement with the initial rating assigned following the grant of service connection for this disability, entitlement to a staged rating for ratings is also for consideration. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). This analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. At the outset, the Board notes that it has reviewed all of the evidence of record, to include in the Virtual VA file (Virtual VA claims processing system) with an emphasis on the evidence relevant to this appeal. (The Virtual File reveals an August 2013 brief submitted by the Veteran's representative, a paper copy of which has been associated with the claims file, but no other pertinent information not physically of record). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, with respect to each claim. A. Shrapnel Wound Scar of the Right Foot The regulations for evaluating disorders of the skin were changed effective October 23, 2008, but only apply to applications for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54708-4712 (Sept. 23, 2008). Because the Veteran filed his claim with respect to the matter of the rating for the right foot scarring in May 2006, the revised regulations do not apply to this claim. The applicable criteria for scars other than of the head, face, or neck, for claims filed prior to October 23, 2008, under DCs 7801 to 7805 as follows: DC 7801 pertaining to scars, other than head, face, or neck, that are deep or that cause limited motion: Area or areas exceeding 144 square inches (929 sq. cm.) warrant a 40 percent rating; area or areas exceeding 72 square inches (465 sq. cm.) warrant a 30 percent rating; area or areas exceeding 12 square inches (77 sq. cm.) warrant a 20 percent rating; and area or areas exceeding 6 square inches (39 sq. cm.) warrant a 10 percent rating. DC 7802 pertaining to scars, other than head, face, or neck, that are superficial and that do not cause limited motion: Area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent rating. DC 7803, scars, superficial, unstable warrant a 10 percent rating. DC 7804, scars, superficial, painful on examination warrant a 10 percent rating. DC 7805, scars, other, will be rated based on limitation of function of affected part. The notes pertaining to these regulations (re-numbered) are shown below: (1) Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. (2) A deep scar is one associated with underlying soft tissue damage. (3) A superficial scar is one not associated with underlying soft tissue damage. (4) An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. (5) A 10-percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. (See § 4.68 of this part on the amputation rule.) [While the amender rating criteria were listed in the March 2009 statement of the case, as applicable to this claim, they are the same in substance as the criteria in effect prior to the October 23, 2008 amendments.] Considering the pertinent evidence of record in light of the above, the Board finds that the criteria for a rating in excess of 10 percent for a shrapnel wound scar of the right foot are not met at any time pertinent to the Veteran's May 2006 claim for increase. Summarizing the relevant facts with the pertinent legal criteria in mind, the service treatment reports indicated the Veteran sustained shrapnel wounds, to include to the right foot, when he was struck aboard a naval vessel by enemy fire from a shore battery while serving in Vietnam. Following separation from service, an October 1968 VA examination demonstrated a half inch scar in the right foot with no bone damage, and service connection was granted for this scarring by an April 1970 rating decision. A noncompensable rating was assigned. This rating was continued until an October 2003 rating decision increased the rating to 10 percent based on June 2003 VA examination that showed pain associated with the scarring. This 10 percent rating has been continued until the present time. With respect to more recent pertinent clinical evidence, a September 2006 VA examiner noted that the scarring in question was "barely visible," not hyper or hypo pigmented, and nine centimeters curvilinear by one eighth of a centimeter in size. There was mild tenderness but no disfigurement, ulceration, adherence, instability, inflammation, tissue loss, keloid formation or abnormal texture. On January 2009 VA scars examination, the Veteran reported constant pain and severe sensitivity to light touch of the skin of the right foot. He also described burning pain that awakens him. The symptoms were said to be so severe that the Veteran could not stand or walk for a long time and that wearing shoes was difficult due to pain. The physical examination showed the scarring in the right foot to measure one centimeter in length by .3 centimeters in width. The scarring was level and with tenderness but without disfigurement, ulceration, adherence, instability, inflammation, edema, tissue loss, keloid, or hyperpigmentation. There was no limitation of motion. Hypopigmentation was shown as well as an abnormal texture of less than six square inches. During the most recent VA scars examination conducted in May 2013, the Veteran described worsening symptoms associated with the shrapnel wound scar of the foot. He described neuropathic related pain on a daily basis aggravated with any weight bearing. The Veteran reported that he woke up at night with severe pain and tenderness with the slightest touch to the foot. He also described color changes around the scar site. It was noted that there was only one painful scar of the trunk or extremities and that there were no scars of the trunk or extremities that were unstable. The scarring in the right foot was said to be superficial and non linear and not deep and to measure 2 centimeters by .3 centimeters. The scarring was said to involve a total area of .6 squared centimeters. The examiner found that due to "severe" neuropathic pain related to the shrapnel wound in the right foot, there was impaired functioning and the ability to work. The examiner stated that there was "chronic neuropathic pain and associated venous insufficiency" in the region of the scarring with decreased sensation and severe hyperesthesia. [Based on these symptoms, a May 2013 rating decision granted service connection for hyperesthesia of the right foot under DC 5284 (Foot injuries, other) at a 10 percent disability rating. The propriety of this rating is not at issue in this decision.] Review of VA outpatient treatment reports dated through May 2012 do not, as applicable to determining the rating for the aspect of the foot disability adjudicated herein, reflect clinical findings describing a level of disability different in severity from that shown at the VA examinations discussed above. The neuropathic pain in the right foot shown at the most recent VA examination is also reflected in the VA outpatient treatment reports. See eg. November 17, 2006, and March 16, 2007, VA podiatry clinic reports. Under DC 7804, superficial scarring that is tender or painful on objective demonstration warrants a 10 percent rating. This is the highest rating available under DC 7804. Given that the most recent VA examination showed the scarring in the right foot to be superficial and that such scarring was said to be "barely visible" at the September 2006 VA examination, it is clear that this scarring is accurately described as being superficial. Thus, the Board finds that this condition is appropriately rated under DC 7804, and emphasizes that the 10 percent rating currently assigned is the maximum rating provided by DC 7804. While the January 2009 VA examiner specifically stated that there was no limitation of motion associated with the scarring in question, to the extent that such scarring in question would otherwise be demonstrated to result in limitation of motion, a rating in excess of 10 percent would require the scarring to be in an area exceeding 12 square inches (77 sq. cm.) under DC 7801. While the size of the scarring has been variously described, it does not approach the size required for a 20 percent rating under DC 7801. In addition, as the service-connected scar has not resulted in ulceration, adherence, instability, inflammation, or tissue loss, it is clear that increased compensation under any other potentially applicable diagnostic code would not be warranted. As there is no evidence that there is any weakness or atrophy associated with the underlying musculature in the area of the service-connected scarring, increased compensation would also not be warranted under any of the diagnostic codes pertaining to the rating of muscle injuries codified at 38 C.F.R. § 4.73. B. PTSD The rating for the Veteran's PTSD has been assigned pursuant to DC 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 30 percent rating is assigned 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). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned 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 100 percent rating is assigned when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on a Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Considering the pertinent evidence of record in light of the above, the Board finds that the criteria for an initial rating for PTSD in excess of 30 percent prior to March 19, 2013, or in excess of 70 percent from that date, are not met. Summarizing the relevant facts with the pertinent legal criteria in mind, the Board notes initially that the record includes a DD Form 214 that reflects that the Veteran was awarded the Purple Heart as a result of his wounds sustained in action in Vietnam. In conjunction with the filing of his claim for service connection for PTSD based on his service in Vietnam, the Veteran was afforded a VA psychiatric examination in March 2010 that resulted in a diagnosis of PTSD. During this examination, the Veteran had difficulty sharing his Vietnam experiences, and was tearful when doing so. He described numerous and recurrent disturbing thoughts and feelings related to his experiences in Vietnam, and reported that has had difficulty falling and staying asleep since that time. The Veteran also described irritability, outbursts of anger, difficulty in concentrating, and hypervigilance. He also described flashbacks of his experiences in Vietnam occurring on average once or twice per month. The Veteran denied significant depression but stated that he feels tearful and sad most of the time. He denied any plans or intentions to hurt himself or others but stated that he has problems controlling his impulses which causes him to become side-tracked and depressed. Frequent panic-like symptoms with heart palpitations, dizziness, and sweats were described. The Veteran reported that he has markedly diminished interest and participation in significant activities and stated that he feels detached and estranged from other people and remains very isolated. On mental status examination, the Veteran appeared to be in no acute distress and was cooperative with examiner. He was well groomed and did not display any bizarre posturing, gait, or mannerisms. The Veteran's mood appeared to be dysphoric with a tearful affect. He denied suicidal or homicidal ideation or intent and his speech was normal in tone and pressure. The Veteran had no looseness of association tangentiality or circumstantiality and denied having hallucinations, delusions, or other psychotic symptoms. His recent and remote memories, concentration, and abstract thinking were intact, and insight and judgment were said to be good. There was no impairment of thought process or communication and no inappropriate behavior or obsessive or ritualistic behavior was noted during the evaluation. The Veteran's rate and flow of speech were not irrelevant, illogical, or obscure in their speech patterns. The assigned GAF score was 62. Under DSM-IV, GAF scores between 61 and 70 are reflective of 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 an individual generally functioning pretty well with some meaningful interpersonal relationships. See Carpenter, 8 Vet. App. at 242-244. The Veteran's prognosis was guarded. Review of VA outpatient treatment reports dated of record dated through May 2012 does not reveal psychiatric impairment that is significantly at odds, in terms of showing more severe psychiatric disability, with that described at the March 2010 VA examination. In this regard, an August 7, 2007, VA psychiatric outpatient treatment report reflected a GAF score (60) almost identical to that demonstrated at the March 2010 VA psychiatric examination, and the GAF score was higher (75) as reflected on an October 23, 2008, VA psychiatric outpatient note than was demonstrated at the March 2010 VA psychiatric examination. Under DSM-IV, GAF scores between 71 and 80 are reflective of, if present, symptoms that are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) with no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See Carpenter, supra. Reports from a January 25, 2012, visit to a VA social worker reflect the conclusion that the Veteran was not suicidal. On March 2013 VA psychiatric examination, in reporting what best summarized the level of occupational and social impairment resulting from psychiatric disability as set forth in the rating criteria, the examiner selected the statement "[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood." As such, the examiner specifically selected the level of disability characterized by a 70 percent rating, and not a 100 percent rating, codified under 38 C.F.R. § 4.130. With respect to the psychiatric symptoms, as described by the rating criteria, demonstrated, the examiner noted that the Veteran displayed a depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss; impaired judgment; disturbance of motivation or mood; suicidal ideation; and disorientation to time or place. The following symptoms (all listed among the criteria for a 100 percent rating) were said to not have been demonstrated at the March 2013 VA psychiatric examination: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); or memory loss for names of close relatives, own occupation or own name. The examiner commented on the notations in the March 2013 VA examination report that the Veteran has frequent nightmares and hyperventilated on one occasion when an another male, upon observing his cap reading "combat wounded," attacked him verbally for killing woman and children. She noted that the Veteran displayed symptoms of major depression including profuse crying. It was indicated that the Veteran was not, due to his religious values, suicidal but that he often feels "very blue and doesn't care about living longer." The Veteran could not remember the day it was but named the correct year and month. It was specifically noted that the Veteran was not claiming that unemployment was due to a mental disorder. The GAF score assigned following the March 2013 VA examination was 45. DSM-IV provides that GAF scores of 41-50 represent serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job, cannot work). See Carpenter, supra. The RO awarded the higher, 70 percent rating from March 19, 2013, which is the date of the March 2013 VA examination set forth above that specifically included an assessment by the examiner that the level of occupational and social impairment required for a 70 percent under the rating criteria were met. Review of the clinical evidence of record simply does not demonstrate that the criteria for a 70 percent rating (or 50 percent rating) for PTSD were met prior to this VA examination and the assessment rendered therein, and the GAF score at the March 2010 VA examination is simply not, in consideration with the other clinical evidence of record, reflective of a level of disability warranting an increased rating prior to March 19, 2013. As for entitlement to a rating in excess of 70 percent from March 19, 2013, the examiner who conducted the examination on that date specifically found that the level of occupational and social impairment required for an increased (100) percent rating, namely, total occupational and social impairment, was not demonstrated. Moreover, while one of the listed criteria (disorientation to time or place) for a 100 percent rating were said to have been met [even though the Veteran was able to identify the correct month and year] none of the remaining criteria (gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; or memory loss for names of close relatives, own occupation or own name) for a 100 percent rating were met at the March 2013 VA examination. While the March 2013 VA examination report clearly reflects diminished social and occupational functioning due to such symptoms as, in addition to disorientation to time or place, a depressed mood, anxiety; suspiciousness, continuous panic or depression affecting the ability to function independently, chronic sleep impairment, mild memory loss, impaired judgment, disturbance of motivation or mood, and suicidal ideation [although when questioned, the Veteran reported that he was not suicidal due to his religious values], the overall disability picture demonstrated by the evidence is not consistent with total occupational or social impairment, as is required for the maximum, 100 percent disability rating. The GAF score of 45 assigned by the March 2013 VA examiner, while indicative of serious disability, does not, when considered in conjunction with other findings from this examination and other evidence of record, demonstrate total occupational and social impairment. In this regard, the Veteran himself told the examiner that he did not contend that he was unemployable due to psychiatric disability, and such a statement would clearly not indicate a degree of psychiatric disability as would equate with total occupational and social impairment. In determining that the criteria for an initial rating for PTSD in excess of 30 percent prior to March 19, 2013, and in excess of 70 percent from that date are not met, the Board has considered the applicable rating criteria not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant increased compensation for the psychiatric disability in question. See supra, Mauerhan. Based on the foregoing, the Board finds that prior to March 19, 2013, the Veteran's psychiatric symptomatology most closely approximated the criteria for a 30 percent rating, and that since March 19, 2013, the Veteran's psychiatric symptomatology has most closely approximated the criteria for a 70 percent rating. See 38 C.F.R. § 4.7. As such, the criteria for a rating for PTSD in excess of 30 percent prior to March 19, 2013, and in excess of 70 percent from that date are not met. C. Other Considerations In assessing the severity of each disability under consideration, the Board has considered the Veteran's assertions regarding his symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings are the required clinical findings that are within the province of trained medical and mental health professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective clinical findings which, as indicated above, do not support assignment of a higher rating for either disability pursuant to any applicable criteria at any point pertinent to this appeal. Additionally, the Board finds that at no pertinent point has either disability under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the March 2009 and July 2012 SOCs). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disabilities at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the applicable schedular criteria are adequate to rate each disability under consideration at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no clinical indication or argument that the applicable criteria are otherwise inadequate to rate either the service connected right foot scarring or PTSD. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). "Because the VA disability rating schedule is designed to consider the disabling effect of disabilities separately, no single DC provision will adequately assess the variety of symptoms involved with multiple service-connected disabilities." Johnson v. Shinseki, No. 10-1785, slip op. at 10 (Vet. App. Mar. 27, 2013) (en banc). Thus, as to the question of "whether [38 C.F.R.] § 3.321(b)(1) requires VA to consider multiple service-connected disabilities on a collective basis" the Court held that it did not. Johnson v. Shinseki, No. 10-1785, slip op. at 4 (Vet. App. Mar. 27, 2013) (en banc) (noting that a concurring opinion in Brambley v. Principi, 17 Vet. App. 20, 27 (2003) that there should have been a determination of "whether the appellant's service-connected disabilities as a whole [sic] entitled [a Veteran] to [an extra-schedular rating] under § 3.321(b)(1)" had never been adopted by the Court and concurring opinions are not binding on the Court" (citing Maryland v. Wilson, 519 U.S. 408, 412-13). Stated in other terms, an extra-schedular rating may not be assigned for the cumulative impact of the service-connected disabilities herein at issue. Finally, the Board acknowledges the fact that if the claimant or the record reasonably raises a question of whether the Veteran is unemployable due to the disability for which a higher rating is sought, then part and parcel to that claim for a higher rating is the matter of whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this regard, the Board notes the fact that the Veteran himself told the VA examiner at the March 2013 VA examination that he was not claiming that he was unemployable due to PTSD. While the April 2013 VA scars examiner indicated that there was some impact on the ability to work associated with the shrapnel wound to the right foot, this was due to the neurological symptomatology, not part of the present appeal, contemplated by the rating assigned under DC 5284, and not the symptomatology associated with the disability rated under DC 7804 that is the matter of this adjudication. There is otherwise no specific evidence or allegation that either service connected disability at issue herein renders the Veteran unable to secure or follow a substantially gainful occupation. As there is no suggestion of actual or effective unemployment due solely to the service connected PTSD or disability due to right foot shrapnel scarring addressed herein, consideration of a TDIU in connection with any higher rating claim on appeal is not warranted. For all the foregoing reasons, the Board concludes that there is no basis for staged rating of the shrapnel wound scar of the right foot, pursuant to Hart, or for any further staged rating of PTSD, pursuant to Fenderson, and that each claim for higher rating must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the assignment of any higher rating for either disability under consideration at any pertinent point, that doctrine is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. ORDER A rating in excess of 10 percent for a shrapnel wound scar of the right foot is denied. An initial rating in excess of 30 percent for PTSD, prior to March 19, 2013, is denied. A rating in excess of 70 percent for PTSD, from March 19, 2013, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs