Citation Nr: 1639123 Decision Date: 09/30/16 Archive Date: 10/13/16 DOCKET NO. 12-32 313 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for a facial scar (s), claimed as a burn scar. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to an initial compensable rating for a left upper extremity scar. 5. Entitlement to an initial compensable rating for a left anterior trunk scar. 6. Entitlement to total disability based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Christopher Loiacono, Agent ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Marine Corps from February 1968 to February 1972. His service included service in the Republic of Vietnam in 1969. These matters come before the Board of Veterans' Appeals (Board) from February 2010 (scars, PTSD and hepatitis C) and April 2014 (TDIU) rating decisions of the Department of Veterans Affairs (VA) Regional Offices (RO) in St. Louis, Missouri and Indianapolis, Indiana. The claims are now properly before the RO in Indianapolis, Indiana. The 2010 rating decision granted entitlement to service connection for PTSD, with an initial 10 percent rating assign effective April 29, 2009. A September 2012 rating decision increased this initial rating to 30 percent, effective April 29, 2009. On his substantive appeals, the Veteran requested a Board hearing. His videoconference hearing was scheduled in April 2016; however, the Veteran did not report. A letter from the Veteran's representative, also dated in April 2016 provided a "waiver" of the Board hearing, and requested that the claims file be held open for 60 days so that additional evidence could be submitted. The Veteran's request for a Board hearing is therefore withdrawn. The claims file was held open for an additional 60 days, with notification to the Agent. The issue(s) of entitlement to service connection for hepatitis C, entitlement to service connection for a facial scar (s), and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. During the period on appeal, the Veteran's PTSD manifested in occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 2. The Veteran's service-connected scars of the left wrist and left flank are superficial nonlinear burn scars of an area less than 939 sq. cm.; the scars were not unstable. The scars occasionally itch, and due to discomfort in the left wrist scar the Veteran is unable to sleep on his left wrist. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 2. The criteria for an initial 10 percent rating for a left wrist scar have been met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.118a, Diagnostic Codes 7802, 7804. 3. The criteria for an initial compensable rating for a left flank scar have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.118a, Diagnostic Codes 7802, 7804. REASONS AND BASES FOR FINDING AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by an October 2009 letter. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With respect to the duty to assist, the Veteran's service treatment and personnel records, as well as his post-service medical treatment records have been obtained. The Veteran indicated he was receiving SSA payments, but it appears they are SSA income payments as an SSA print out from March 2015 indicated he was not receiving SSA disability benefits. The Veteran has not identified any private records that he wished for VA to attempt to obtain. The Veteran was afforded VA psychiatric examinations in December 2009 and February 2013. He was afforded a VA scar examination in October 2009. The examiners reviewed the Veteran's claim file, past medical history, recorded his current complaints, conducted an appropriate evaluation, and rendered an appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that the examination reports are adequate for the purpose of rendering decisions on the current appeals. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. The Veteran was provided with the opportunity to testify at a hearing, but he declined this opportunity. Thus, the duties to notify and assist have been met, and the Board will proceed to a decision. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). PTSD The Board notes that the Veteran's service-connected PTSD is evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. The Board notes that the DSM-IV has been recently updated with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5th Edition (2013) (DSM V). Effective March 19, 2015, VA adopted as final, without change, its' interim rule amending the portion of its Schedule for Rating Disabilities (i.e., 38 C.F.R. §§ 3.384 , 4.125, 4.126, 4.127, and 4.130) dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. See 53 Fed. Reg. 14308 (March 19, 2015). However, the provisions of the rule only apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. During his period of appeal, the Veteran's PTSD symptoms have been addressed by the 2013 examiner and the VA under the DSM-IV and DSM-V. His 2013 VA examination provided a diagnosis of PTSD under the DSM-V. Additionally, his claim stems from 2009. The Veteran's service-connected PTSD has been evaluated as 30 percent disability under 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria for rating psychiatric disabilities other than eating disorders are contained in a General Rating Formula. Under that formula, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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 work-like setting); and inability to establish and maintain effective relationships. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. See 38 C.F.R. § 4.130, DC 9411. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association 's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). In January 2009, the Veteran sought VA mental health treatment after presenting with complaints of difficulty sleeping due to nightmares containing combat content. He stated these nightmares occurred most days of the week and roughly two to three times per night. He stated he did not want to talk about specific combat experiences, but noted he lost many friends in combat. He struggled to allow others to gain his trust, which would take time. He described his mood as "ok," and his affect was constricted throughout most of the session, although he evidenced humor and laughter near the end of the meeting. His speech was normal and his thoughts were linear. On testing, the Veteran indicated the following bothered him "quite a bit:" disturbing dreams related to military combat, desire to avoid situations reminding him of military experience, feeling distant from others, feeling emotionally numb, trouble staying asleep, difficulty concentrating, hypervigilance, and easy startle response. He reported a good relationship with his children, and he enjoyed hunting, fishing, and crossword puzzles. He also tended bar for the VFW. He stated he would think about treatment options discussed during the session. He indicated he did not feel comfortable talking about military circumstances with the psychologist, but that he would feel comfortable talking with other Veterans. The Veteran was afforded an initial PTSD examination in December 2009. He reported psychiatric symptoms of depression and anxiety. He felt that the symptoms were severe and continuous. He reported outpatient care due to psychiatric symptoms in 1987 at Bridgehouse Richmond State Hospital, for PTSD, depression and anxiety. Other records indicate the Veteran sought substance abuse treatment at Bridgehouse. He stated he tried prescription medication for sleep at one point, but that it did not work for him (a date was not provided). He reported that he had three siblings, but that he was not "close" with them and saw them only on holidays. He had two adult children, and was divorced from their mother. He indicated his daughter called him by his first name, and that his ex-wife had "turned his children against him." Regarding friendships and leisure activities, the Veteran reported he volunteered at his local VFW, went hunting and fishing, and had a female friend who accompanied him to the interview. The Veteran stated he lost many good friends in Vietnam. He was also badly burned in Vietnam. The Veteran reported severe flashbacks and feeling as if the trauma were recurring four to five days per week, he reported severe nightmares five to six times per week, he avoided thinking about the trauma, was unable to recall important aspects of the trauma, and he avoided crowds. He also felt detached from others and had a restricted range of affect. He endorsed symptoms of : impaired sleep, being irritable, difficulty concentrating, hypervigilance, and easy startle response. On mental status evaluation, the Veteran had no impairment of thought process or communication. He had no delusions, hallucinations, suicidal plans or intent, or homicidal plans or intent. He did not have hygiene problems or memory impairment. He denied panic attacks or obsessive or ritualistic behaviors. He endorsed daily, moderate to severe depression and anxiety. When asked how his depression interfered with employment and social functioning, he stated he was not able to work. The examiner noted the Veteran did not report problems with impulse control. He had severe sleep impairment, such that he stated he could not sleep nightly and that he was "fatigued." He reported alcohol use, which he had recently decreased at the advice of his physician. He reported his drinking began after Vietnam. He was diagnosed with PTSD with depression and anxiety under the DSM-IV. The examiner noted the Veteran "probably medicates himself with alcohol; he does not drink every day." The examiner felt it was not possible to describe an independent impairment caused by his substance abuse because the examiner felt that his alcohol use was how the Veteran "medicated himself." The examiner found that the Veteran's PTSD symptoms resulted in "deficiencies in most of the following areas: work, school, family relationship, judgment, thinking and mood." The examiner noted the Veteran was a "loner" but that he had a live-in girlfriend and one close friend who came to the interview with him. He was "not able to work." In March 2010, the Veteran called and asked if the VA psychologist would be able to write a letter in support of his request for an increased rating for PTSD. She explained that she last met with the Veteran over a year ago and that usually a clinician would only write a letter in support after having worked with a patient for a significant amount of time so that they are familiar with the patient's history. The Veteran expressed interest in the PTSD clinic and he was sent a brochure. In October 2010, the Veteran was referred to VA mental health due to concerns from his physicians regarding PTSD and alcohol consumption. The Veteran was contacted by a VA psychologist by telephone. The Veteran denied depressed mood and anhedonia. He stated he enjoyed life, attended the VFW and was spending his retirement reading. He reported he had difficulty sleeping, and had dreams related to military service two to three times per week. He stated he had lived with these dreams for a long time and they were not worsening. He reported that over the past week he had cut down his alcohol use from six beers per day to two beers per day in response to his physician's urging. He denied suicidal/homicidal ideation and he declined to make an appointment with the psychologist. He was given her phone number to call should his symptoms increase, or if he changed his mind. A February 2012 "psychology triage" note indicated the Veteran self-referred for care. He reported sleeping three to four hours at night, but felt he was only sleeping about 20 to 30 minutes at a time before waking again. He reported his traumatic incident in service as his being badly burned in Vietnam and being hospitalized for 8 months. He reported flashbacks regarding his burning two to three times per week and being bothered "quite a bit" by flashbacks, dreams, reliving his memories, physical reactions, avoidance, feeling jumpy and feeling emotionally numb. He felt that his symptoms had increased in the past six to 12 months. He felt that his mood was "ok" but that he also had "fits of anger about what's going on in the world." He denied an interest in anger management services, stating that his anger passes. When asked about suicidal ideation, he stated he had "occasional low-grade thoughts about taking his own life, but denied plan or intent." He then stated he would never take his own life for religious reasons and because he never knew what exciting, good thing might be around the corner. Regarding homicidal ideation he reported thoughts of wanting to hurt or kill people in the news who rape or murder children, but he did not have any particular individual in mind or a plan to hurt anyone. He then indicated those people would not be worth the time in jail if he did hurt them, and he instead wished that they were in jail. These thoughts were fleeting, and usually around just when he was learning about the crimes (reading or watching television). The Veteran indicated he did not think he would be able to talk about his experiences to non-veterans and was interested in group therapy. On mental status evaluation, he reported an "okay" mood. His speech was normal. He felt he had some difficulty with short term memory, but he stated he wasn't concerned about it. He denied hallucinations and delusions. His affect was "slightly constricted, but he also laughed during the session." He was referred for group services. Also in February 2012, the Veteran was given a psychiatric assessment. He reported he had nightmares and could not sleep "anymore." He wanted to "get into one of those groups for PTSD." He also reported intrusive thoughts regarding Vietnam, avoidance of crowds, and limiting his activities due to PTSD. He felt his symptoms had been constant for the past six months. He reported no prior or current PTSD treatment. He described ongoing difficulties with alcohol throughout his life. Prior to treatment in the late 1980s he would drink a 12-pack of beer per day. Less so since then, but physicians had warned him his ongoing alcohol consumption was bad for his liver. He described good relationship with his siblings, girlfriend, and some friends. He had leisure activities of hunting and fishing. He indicated the dissolution of his first marriage was due to his wife overspending. He indicated his wish for psychological treatment was to get rid of his nightmares and "find people I can relate to." On mental status evaluation, the Veteran's appearance was normal, his attitude toward the evaluator was "guarded," his speech was normal, and he described his mood as "good." He stated his sleep was impaired by nightmares, which had increased in the prior six months. He had an appropriate affect. He indicated anxiety regarding nightmares and sleep. He denied hallucinations and delusions. His thought-processes were linear. His memory and judgement were intact, and his insight was fair. The evaluation included that the Veteran had been cutting down on alcohol consumption and that he would be willing to stop to be able to attend a PTSD treatment program. He was given a GAF score of 55. In March 2012, the Veteran sought VA treatment due to getting only two or three hours of sleep per night, and wanting "to get a better night's sleep." He also wanted less hypervigilance. He was noted to have "been employed and maintains stable relationships." He was scheduled for 12 weeks of psychotherapy. His initial session was in late March 2012, and noted his sessions should continue through most of June. His initial symptom complaints were of hypervigilance and intrusive thoughts. The sessions were noted to be aimed at "more fully emotionally processing the traumatic event." He was noted to not be suicidal. During his second session, the Veteran struggled with some of the worksheets monitoring his daily thoughts and feelings and discussing the impact of his trauma on his life as he did not "write well" and did not like to "talk badly to myself about myself." His third therapy session noted the Veteran had some "dysfunctional thoughts" related to worksheets he completed to understand the relationships among thoughts, feelings, and behaviors to daily events. This is not elaborated upon in the notes. The Veteran's fifth therapy session in late April 2012 was his last. He reported continued hypervigilance and intrusive thoughts. The Veteran had a practice assignment related to rewriting his traumatic event, and he reported a decrease in distress related to this assignment as compared to his prior session. Following the session, the Veteran stated he did not "need to do any of the modules. [He was] feeling fine at this point." The clinician noted the Veteran was not homicidal or suicidal and "doing well." The clinician noted the Veteran did "not need to continue," and let the Veteran know to return if he ever wanted additional services. The Veteran was afforded a second PTSD examination in December 2013. The Veteran was assessed with mild PTSD and alcohol use disorder. The examiner noted that "a small portion" of the Veteran's sleep impairment was due to his PTSD, and that a "larger portion" was due to his alcohol use disorder. The examiner noted the occupational and social impairment due to the Veteran's PTSD was that it had been formally diagnosed, but symptoms were not severe enough either to interfere with occupational and social function or to require continuous medication. During the interview, the Veteran reported that he did not experience any social or occupational impairment; however, the Veteran's healthcare providers have encouraged him to decrease his alcohol consumption due to negative health effects. The Veteran described two stressful in-service incidents. One involved a dental lab being hit by a rocket, and the Veteran knew four of the eight men killed. His second incident was when a "mortar round hit a fuel cell" and he was burned. During treatment for his burns they used a cream that contained an ingredient he was allergic to, which caused the feeling of being burned a second time. His pain was also not well-controlled during treatment. Regarding his relationships, the Veteran indicated he had good relationships with his sisters and children. He and his first wife divorced due to financial, and possibly religious, differences. He reported he saw his adult children roughly every six months. He was in a relationship with his current girlfriend for 11 years and there were "no problems" in the relationship, although they did not sleep together due to his restless sleep. He reported enjoying reading, television, and recreational shooting. He also reported some friends, and four or five close friends. He stated he was "enjoying retirement" and he had "plenty to do." He gave a detailed work history, which included working several jobs, sometimes more than one at a time, where he was able to get along with bosses, coworkers, and customers. For 13 years he worked at a chain store, and he had no problems and was a good worker until he had a supervisor who "made [him] make the decision to leave." She called the Veteran's mother a name and so he quit the next day. He indicated that he was worried any additional confrontations with the supervisor would lead him to physically harm her, so he quit. He stated he "retired after that" but that he had done some small jobs, like working for the census bureau for a few weeks. The examiner cited several VA treatment records regarding the Veteran's PTSD and alcohol use. Regarding his alcohol use, the Veteran stated he began drinking at age 13 or 14 years old. He continued drinking in high school and college, mostly on the weekends. He inferred that his drinking impacted his college education, and stated that he would drink until he was drunk. His drinking continued throughout military service, with limited drinking in Vietnam due to limited access to alcohol. He indicated his drinking increased after his divorce in 1978. From 1978 to 1988 he considered his drinking to be "heavier." After a DWI in 1988 he cut down on his drinking, and would drink two to five drinks a day, but never to the point of getting drunk. He stated this is still his drinking habit. The examiner noted that the Veteran still met the DSM-IV criteria, and also met the DSM-V criteria, for PTSD. His symptoms were "extremely mild and do not appear to cause any discernible social or occupational impairment. At most, they are associated with mild degrees of subjective distress." The examiner noted that the Veteran had a few session of treatment for PTSD in March and April 2012 prior to discontinuing treatment. Thus, the examiner noted the Veteran's symptoms were so mild and transient that they did not require ongoing individual therapy or medication. The Veteran reported good familial relationships, and an excellent work history. He also reported enjoying numerous leisure activities. He had the symptoms of re-experiencing, in that he had nightmares about being burned, and nightmares of war. He also did not like crowds and avoided them. He had feelings of distrust regarding both the government and the world --"no one can be trusted." He had sleep impairment, noted to be both due to his PTSD and his alcohol use. He denied irritability. He did endorse easy-startle response, but he did not think that it "caused any problems." He endorsed hypervigilance, and stated he was always alert. He stated that it did not stop him from doing anything he wanted to do. He denied concentration issues, and none were evident during the examination. "There is no discernible functional impairment caused by the Veteran's PTSD symptoms." He denied suicidal ideation, fatigue, feelings of worthlessness, depressed mood and loss of interest. On mental status evaluation, the Veteran's eye contact was appropriate, his speech was normal, his affect was "full; bright," his mood was happy, and his thought content was normal. He denied delusions, hallucinations, and obsessions/compulsions. He stated he sometimes had a panic attack while asleep, and it would cause him to wake up. He reported six to seven hours of sleep each night, and drinking two and a half pots of coffee per day. He maintained appropriate hygiene, had normal abstract reasoning, denied episodes of violence or impulsive behavior. He was noted to have adequate judgment and insight. An August 2013 primary care note indicated a history of PTSD and depression, but that the Veteran was "stable." The Veteran denied psychiatric symptoms. A February 2014 primary care note indicated the history of PTSD and depression, and again noted the Veteran was "stable." The Veteran stated his mother was in a nursing home and 92-years old, so he was worried about her, but that otherwise he was "ok." He did not want medication or counseling and he denied suicidal ideation. An April 2014 note indicated that it had been two years since the Veteran had sought VA mental health treatment. He denied mood swings, depression or suicidal thoughts. He was noted to have a history of PTSD, but he stated he did not want any medications related to his diagnosis. He also declined any further assistance for his PTSD. He continued to have moderate alcohol use and was advised to quit. The Veteran was noted to have been discharged from hepatology in 2012 due to continued alcohol abuse. The Veteran's last psychotherapy session in April 2012 appears to have been his last treatment with the VA regarding his PTSD diagnosis. Although other records noted continued alcohol use, there are no records related to substance abuse treatment. The Board notes that in adjudicating a claim the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In addition, the Board acknowledges that the Veteran is competent to give evidence about what he experiences; for example, he is competent to report that he experiences certain symptoms, such as his problems with intrusive thoughts, nightmares, and irritability. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Here, the Board finds the Veteran's description of his PTSD symptoms to be credible. Throughout the appeal process, the Veteran has reported that his sleeping has been severely impacted by his PTSD due to frequent distressing nightmares. He has also continued to report hypervigilance, easy-startle response, and distrust (which includes a dislike of crowds). Although the Veteran's use of alcohol was noted to have started at a young age and to have impacted his education prior to his enlistment in service, the record is not clear as to whether his service/PTSD aggravated his alcohol use. He has stated that his alcohol use "picked up" after his divorce in 1978, but at least one VA examiner has indicated he used alcohol to "self-medicate" his PTSD symptoms. Since there is no consensus on this, the Board will treat the Veteran's alcohol use as a symptom of his PTSD, to afford the greater benefit to the Veteran. The Veteran and his representative contend that his PTSD warrants a rating in excess of 30 percent. The Board finds that the Veteran's PTSD symptoms have decreased in severity throughout the appeal process, and that they fall between the 10 percent and 30 percent ratings. Affording the Veteran the benefit of the doubt, his symptoms have more nearly approximated the 30 percent rating criteria throughout the appeal. As described above, the Veteran's PTSD has manifested in symptoms of: sleep impairment, hypervigilance, easy startle response, alcohol abuse, irritability, avoidance of crowds, intrusive thoughts, avoidance of topics associated with war, suspiciousness (lack of trust), and mild memory/concentration impairment. In December 2013, he stated he sometimes has panic attacks in his sleep. In February 2012, the Veteran reported "low-grade" thoughts regarding suicide, but, without prompting, then corrected that he would never commit suicide due to religious views and that the future may hold better things. Otherwise, during treatment and testing, he consistently denied suicidal ideation. A rating in excess of 30 percent for the Veteran's PTSD is not warranted as his PTSD has not manifested in symptoms such as abnormal speech (consistently noted to be normal), panic attacks more than once a week (he frequently denied panic attacks), difficulty understanding complex commands (none of the records have indicated thought deficiencies), impairment of short- and long-term memory (he has indicated minor short-term memory impairment and some loss of the immediate memories surrounding his stressful incidents), impaired abstract thinking, and difficulty in establishing and maintaining effective work and social relationships. The Veteran was successfully employed without incident for a number of years and reported good working relationships until one manager made derogatory comments about his mother. This lone incident of a work-relationship problem, as described by the Veteran, appeared to be caused by the other party and was handled appropriately by the Veteran (he chose to retire instead of retaliating). The Veteran has a history of divorce; although, again, this appears to be largely a problem of his ex-wife overspending. He has maintained a relationship with his adult children despite the divorce when they were children, and he has had an ongoing relationship with a woman (girlfriend) for more than 10 years. He has also reported several friendships, leisure activities, and social acquaintances through the VFW. The Veteran indicated some level of depression and anxiety during the course of the appeal, but since 2012 has indicated that his mood has improved to "good" and "ok." The record contains one GAF score of 55 (moderate symptoms) from February 2012. He has managed to maintain his mild to moderate level of PTSD symptoms with limited individual therapy (it is unclear from the record why the Veteran was never placed in the group therapy he wished to participate in), and without the use of any prescription medications. Regarding his judgement, the Board notes that it is generally fair and he has had no disruptive interactions with others or involvement with the police in more than 25 years. The Board does note that his alcohol use can be considered inadequate judgment/insight for the purposes of rating, and this has been taken into account in maintaining the 30 percent rating despite the Veteran's reported lessening of other PTSD symptoms from 2012 to the present. As such, the Board finds that a rating in excess of 30 percent is not warranted. The Board notes that the 2009 VA examiner described the Veteran's PTSD symptoms as resulting in deficiencies in most areas, which is the wording for the criteria for a 70 percent rating in the regulations. However, a review of the 2009 examination shows that the Veteran's symptoms did not meet the criteria for a 50 percent, or higher. During that examination, the Veteran denied delusions, panic attacks, and obsessive behaviors. He had normal hygiene and communication. He functioned independently and maintained impulse control and he continued to maintain a relationship with a girlfriend, a close friend who went to the examination with him, and several other friendships and social relationships through leisure activities and the VFW. The Board takes the details of the mental status evaluation and the symptoms reported (and denied) by the Veteran to be a better judge of the severity of his PTSD symptoms than the choice of words ("deficiencies in most areas") provided by the examiner. In summary, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting a higher disability evaluation for the Veteran's service-connected PTSD. Thus, the benefit sought on appeal is denied. Scars Initially, the Board notes that the regulations pertaining to the evaluation of skin disabilities were amended effective October 23, 2008. As the Veteran's claims were filed after this date, only the amended regulations apply in this case. Under Diagnostic Code 7801, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. A scar in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm) warrants a 20 percent evaluation. Under Diagnostic Code 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (2) under that code provides that if multiple qualifying scars are present, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity. Diagnostic Code 7804 assigns ratings for scars that are unstable or painful. A 10 percent rating is assigned for one or two qualifying scars, a 20 percent rating for three or four qualifying scars, and a 30 percent rating for five or more qualifying scars. Note 1 under the diagnostic code provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804. In October 2009, the Veteran was afforded a VA scars examination. The examiner noted the Veteran had a scar on his left ventral wrist consisting of a patch of hyper-and hypopigmented skin, and a scar on his lateral lower left abdomen that also consisted of a patch of hyper-and hypopigmented skin. The Veteran reported that the scars occasionally itched and that he was unable to sleep on his left wrist scar, presumably due to discomfort. The left wrist scar was 2.5 cm. by 5.5 cm., the left flank scar was 3.5 cm. by 17 cm. The examiner noted that neither scar was painful or showed signs of skin breakdown. The scars were both superficial, without inflammation or edema. The Veteran did not have keloid formation and there were no other disabling effects from the scars. The examiner noted that although the Veteran reported the scars would occasionally itch, he did not require any topical treatment. There are no other treatment records or VA examinations associated with the Veteran's left wrist and left flank scars. Although the Veteran provided an notice of disagreement and substantive appeal regarding his wish for increased ratings for his scars, neither he nor his agent provided any substantive argument for increased ratings. As noted above, during the October 2009 VA examination, the examiner noted that the Veteran's scars were not painful during examination. However, the Veteran reported he could not sleep on his left wrist due to the scar. Although it is not specifically stated, the Board infers that this is due to discomfort. As such, the Board will resolve reasonable doubt in the Veteran's favor, and finds that his left wrist scar is "painful" such that it warrants a 10 percent rating under Diagnostic Code 7804. Notably, this rating is for one or two scars that are unstable or painful. The Veteran's left flank scar was noted to not be painful on examination and the Veteran did not indicate any pain associated with it during the examination. Additionally, as both scars are superficial and of an area of less than 939 sq. cm., increased ratings under Diagnostic Codes 7801 and 7802 are not warranted. As such, the Board finds that an initial 10 percent rating is warranted for the Veteran's left wrist scar and finds that an initial compensable rating for the Veteran's left flank scar is not warranted. Extraschedular An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321 (b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation regarding PTSD is adequate. The PTSD disability symptoms are contemplated by the schedular criteria and additional higher ratings are available. The Board has noted when the Veteran's symptoms span different ratings under the criteria, from mild to moderate. The balance of his symptoms were of a moderate severity during this period, and as such the 30 percent rating was assigned. The criteria under the General Rating Formula for Mental Disorders is inclusive, in that it allows for a variety of symptoms to be applied to the ratings as long as they are of a similar severity and produce a level of occupational and social impairment. The Board discussed why the Veteran's symptoms fell between the 10 and 30 percent ratings, and addressed why the Veteran's reported symptoms did not reach the next higher level of symptoms associated with an increased rating. As such, the diagnostic criteria reasonable describe and contemplate the severity and symptomatology of the Veteran's PTSD. The Veteran has had limited treatment for his PTSD and, although his alcohol use negatively impacts his health, he has not been hospitalized in relation to his PTSD symptoms. The Board does not find that this constitutes marked interference or frequent hospitalization for the purposes of an extraschedular rating. As the rating schedules are adequate to evaluate the disabilities, referral for extraschedular consideration is not in order. Regarding the regulations for the Veteran's scars, the Board notes that "itching" is not a part of the criteria for rating scars. As such, there is an unusual disability picture regarding the Veteran's scar ratings. Notably, if there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. The Veteran stated that he has occasional itching of the scars, but that he has never sought treatment, to include topical treatment for the itching. When discussing his employment history during PTSD examinations, the Veteran indicated continued employment for many years, and occasionally working more than one job at a time. When applying for TDIU, the Veteran stated that his PTSD was the reason he was unemployable. As such, the record does not show that the itching has resulted in interference with employment or any periods of hospitalization. In fact, the Veteran has not sought treatment for his scars since discharge. Therefore, the Board will not refer the claims for consideration of the assignment of an extraschedular rating. ORDER Entitlement to an initial rating in excess of 30 percent for PTSD is denied. Entitlement to an initial 10 percent rating for left wrist burn scar is granted. Entitlement to an initial compensable rating for a left flank burn scar is denied. REMAND Hepatitis C Initially, the Board notes that the Veteran has not been afforded a VA examination in relation to his claim for service connection for hepatitis C. The record currently contains limited information regarding his hepatitis C history, to include a history of possible transmission. He has previously denied illicit drug use other than marijuana. He has also indicated that he was unsure if he received a blood transfusion in service when he was being treated for his burns in Vietnam and Japan. A review of the available service records includes treatment records from after he returned from his hospitalization in Japan, but does not include treatment records from treatment in Vietnam or Japan. On remand, an attempt to obtain these missing records should be made and the Veteran must be afforded a VA examination. Facial Scar The Veteran is seeking service connection for facial scars associated with his burn incident in Vietnam. A review of his service treatment records shows that, separate from the burns he suffered in Vietnam, he also sustained "flash burns to both eyes" in January 1971. Also, an entrance exam does not indicate facial scars, but following a January 1971 car accident, the Veteran had a laceration to his face that required stitches. Upon discharge he was noted to have a 4-inch scar on his forehead. The VA scars examination did not indicate that the Veteran had any facial scars; however, given that his service treatment records showed a 4-inch scar upon discharge that was not noted during enlistment, the Board finds that a second VA examination must be provided. TDIU Currently, the Veteran's combined service-connected disability ratings are 50 percent (taking into account the 10 percent rating for left wrist scar). Although a 40 percent rating for "one" disability is met because the Veteran's PTSD and his left wrist scar were a result of a "common etiology or a single accident" (his in-service burn), he currently does not have additional disabilities that combine to a 70 percent or greater. As such, he does not currently meet the jurisdictional requirements of 38 C.F.R. § 4.16 for TDIU. Currently, the record does not contain a medical opinion regarding the Veteran's ability to function in an occupational environment or that describes the functional impairment caused solely by his service-connected disabilities. The Veteran is currently service-connected for PTSD, hearing loss, tinnitus, and scars. His claim for hepatitis C and an additional scar evaluation are being remanded. As such, a VA examination addressing the combined functional impairment of his service-connected disabilities must be provided. Accordingly, the case is REMANDED for the following action: 1. Obtain, if possible, service treatment records for the Veteran's period of hospitalization in Vietnam and Japan in 1969. If these records are unavailable, provide a memorandum of unavailability. 2. Schedule the Veteran for a hepatitis C examination. After a review of the record, and interview of the Veteran, the examiner should provide the following opinion: Is it at least as likely as not (50/50 probability or greater) that the Veteran's hepatitis C was transmitted/contracted in service? The examiner must provide a detailed explanation for all opinions expressed. 3. Schedule the Veteran for a scars examination. After a review of the record, and examination of the Veteran, the examiner should answer the following: a) Does the Veteran have any facial burn scars? If so, a complete description is necessary. The examiner should note the 1971 record of "flash burns to the eyes." b) Does the Veteran have a facial laceration scar? If so, a complete description is necessary. The examiner should note the 1970 record detailing a forehead laceration and the separation examination describing a forehead scar. 4. Schedule the Veteran for a VA examination regarding his claim for TDIU. Any examination conducted must describe any functional impairment resulting from service-connected disabilities, and identify all symptoms and manifestations that could conceivably affect his ability to perform either physical or sedentary employment. A detailed work and education history should also be reported. 5. After completion of the above and any additional development deemed necessary, the issue on appeal must be reviewed with consideration of all applicable laws and regulations. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs