Citation Nr: 18156074 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-47 087 DATE: December 6, 2018 ORDER 1. Staged increased ratings of 50 percent from March 1, 2004 and 70 percent from August 23, 2012 are granted for other specified trauma and stressor-related disorder, subject to the regulations governing payment of monetary awards; a rating in excess of 10 percent prior to March 1, 2004 is denied. 2. Entitlement to increases in the (0 percent prior to October 12, 2011, 30 percent prior to April 14, 2016, and 0 percent from that date) ratings for dermatitis is denied. FINDINGS OF FACT 1. Prior to March 1, 2004, the Veteran's other specified trauma and stressor-related disorder is not shown to have been more than mild; from March 1, 2004, it is reasonably shown to have been productive of occupational and social impairment with reduced reliability and productivity; from August 23, 2012, it is shown to have been manifested by symptoms productive of occupational and social impairment with deficiencies in most areas. 2. Prior to October 12, 2011, the Veteran's dermatitis did not involve an extensive area or result in exfoliation or exudation and involved less than 5 percent of the entire body or exposed areas; from October 12, 2011 through April 13, 2016, the dermatitis required systemic treatment for less than six weeks a year, did not involve more than 20 to 40 percent of the entire body or exposed area, and did not require constant or near-constant treatment; from April 14, 2016, the dermatitis has required no more than topical therapy and has involved less than 5 percent of the entire body or exposed areas. CONCLUSIONS OF LAW 1. Staged increased ratings of 50 percent from March 1, 2004 and 70 percent from August 23, 2012 are warranted for the Veteran’s service connected psychiatric disability; a rating in excess of 10 percent for the disability is not warranted prior to March 1, 2004,. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code (Code) 9413. 2. A compensable rating for dermatitis prior to October 12, 2011, a rating in excess of 30 percent from October 12, 2011 through April 13, 2016, and a compensable rating from April 14, 2016 are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Code 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from October 1974 to December 1976 and from December 1990 to May 1991. These matters are before the Board of Veterans' Appeals (the Board) on appeal from a July 2014 rating decision by the Regional Office (RO). In November 2014, the Board remanded these matters. In March 2014, the Board granted service connection for the psychiatric disability and dermatitis. A July 2014 rating decision assigned a 10 percent rating for the psychiatric disability from January 8, 1993; a 30 percent rating from September 18, 2007, and a 50 percent rating from August 23, 2012. The July 2014 rating decision also assigned a 0 percent rating for dermatitis, effective November 24, 1993. A July 2016 rating decision assigned a 100 percent rating for the psychiatric disability effective October 21, 2015; and a 30 percent rating for the skin disability, from October 12, 2011 and a 0 percent rating from April 14, 2016. In January 1993, the Veteran was admitted to a VA hospital for alcoholism. He reported anxiety attacks and trouble sleeping. On mental status evaluation, his affect was blunted. There was no looseness of associations or flight of ideas. He was alert and cooperative. His mood was euthymic and his affect was appropriate. His memory was intact. There was no current suicidal or homicidal ideation. He denied delusions or hallucinations. His judgment was fair when sober and his insight was superficial. The diagnoses were alcohol dependency and borderline personality disorder. On February 1993 VA psychiatric examination, it was noted that the Veteran was a heavy drinker and could not sleep at night. It was noted that he sometimes had a skin rash that comes and goes. His affect was somewhat blunted and his mood neutral. He complained of memory problems. He was well oriented. The diagnostic impressions were generalized anxiety disorder, panic disorder without agoraphobia, alcohol dependence, organic anxiety disorder and organic personality disorder secondary to alcoholism or brain injury. On July 1993 VA hospitalization, it was noted that the Veteran had numerous vague symptoms with no objective findings. Mental status evaluation found him to be an unreliable historian due to high levels of anxiety and memory troubles. His perception was reality based. He had mild to moderate anxiety, but no bizarre mannerisms. His affect was appropriate. He was oriented times four. He had no abnormal thought content. There were no active delusions or hallucinations. His judgment was not impaired. The diagnoses were alcohol dependence, continuous, history of drug abuse and history of treatment for depression and anxiety reaction, including suicidal attempts. VA outpatient treatment records show that in July 1993 the Veteran was noted to have an erythematous rash mainly along the medial side of both arms. It burned, but did not itch. Some very fine papules were noted with the rash. The assessment was rash. VA outpatient treatment records show that in April 1994, the Veteran stated that he felt jumpy, was not sleeping and was nervous all the time. He said that he had nightmares. Examination found that his mood was dysphoric and his affect flat. He was not psychotic. It was noted that he had memory loss. The impressions were posttraumatic stress disorder (PTSD) and panic attack. In May 1994 it was noted that he was anxious and irritable. He had some intrusive thoughts of war. His mood was depressed and he had a flat affect. He was not psychotic. The impression was PTSD. In August 1994, he stated that he had a rash on his stomach. The diagnostic impression was rash. Service department records show that in September 1994 the Veteran was seen for a Persian Gulf War evaluation. He reported anxiety, depression and night sweats. He was seen by psychiatric service and it was noted that he had major depression, panic disorder, PTSD, alcohol dependence and a cognitive disorder. He was also evaluated for a skin rash by dermatology and was found to have atopic dermatitis and tinea pedis. Service department records show that in October 1994, the Veteran presented for a Persian Gulf evaluation. He reported somatic complaints including memory loss, a skin rash, nightmares, anxiety attacks and feelings of depression. It was noted that he was on medication for psychiatric problems and that he used various steroid creams for his skin condition. On mental status evaluation, the Veteran was alert and oriented. His speech was quick at times, but not pressured. His affect was restricted. He was notably angry, frustrated and guarded. His thought process was somewhat tangential and circumstantial. Thought content predominated on anger. At times, he displayed mild paranoid ideation, but it did not appear to be delusional in intensity. He denied audio or visual hallucinations and suicidal or homicidal ideation. The diagnoses were major depression, single episode; panic disorder without agoraphobia, in remission; PTSD; personality disorder; and rule out cognitive disorder. On October 1994 psychological evaluation (as part of the Persian Gulf evaluation), it was noted that the Veteran reported some very odd beliefs of a paranoid nature, suggestive of a thought disorder. VA outpatient treatment records show that in September 1994, the Veteran stated that he was still very nervous and was under heavy financial pressure. He reported continued anxiety and nightmares. His mood was dysphoric and his affect flat. He was not psychotic. In November 1994, he reported continued anxiety and intrusive thoughts. His mood was dysphoric and his affect flat. In April 1995, he stated that he had lost his job and had problems sleeping. He said he had occasional nightmares. He was very anxious during the day. His mood was depressed and his affect flat. He was not psychotic. Social Security Administration (SSA) records show that in August 1995 the Veteran was seen for a psychiatric evaluation. He stated that he had anxiety attacks and that he gets depressed. He stated that he spends a typical day sitting in his garage thinking about his problems. Mental status evaluation found that he did not appear to be unusually tense, but spoke of becoming irritated extremely easily. There were no suggestions of disorientation or acute anxiety. He had no manic symptoms such as flight of ideas, pressured speech or tangential thinking. He did not report ever having had hallucinations or delusions, but believed that the Government was trying to hurt him. He was bitter about his experiences in service. The examiner noted that the Veteran said his sleep was poor, but he did not appear to have problems with low energy or fatigue. He had some feelings of worthlessness. He did not have suicidal thoughts. Attention and concentration appeared to be mixed. His judgment was fair and his thinking concrete. The diagnoses were alcoholism, in partial remission; major depression, in remission; panic disorder; and possible PTSD. The examiner noted that the Veteran apparently had some panic attacks, but they were less frequent than they had been in the past. On August 1995 general medical examination for the SSA, examination of the skin found no lesions. Private medical records show that in September 1995, the Veteran stated that he had a rash that appears sometimes at night with itching. VA outpatient treatment records show that in March 1996, the Veteran stated that he was feeling a lot of stress and was not sleeping well. Mental status evaluation showed that his mood was depressed and his affect flat; he was not psychotic. In July 1996, he was irritable and angry about termination from his VA job. He was also having family problems. Examination found his mood was dysphoric and his affect flat. He was not psychotic. The impression was PTSD. In September 1996, he stated that he was very angry and irritable and that he had violent thoughts. His mood was depressed and his affect labile. He was not psychotic. In June 1999, he was seen in a mental health clinic and was alert and fully oriented. His mood was anhedonic and his affect very serious and irritable. There was no suicidal or homicidal ideation and he had no psychotic symptoms. It was noted later in June 1999 that medication helped reduce his anxiety. It was also noted that he continued to have rashes. In October 2000, he stated that he had been fired from his job which he had held for nine months. Mental status evaluation found that he was alert and oriented. He had a rather depressed mood and anxious affect. Thought process and thought content were impaired with sociopathic ideas. He felt that he is a victim. He denied suicidal or homicidal ideation. The assessment was adjustment disorder. In November 2003, it was noted that he was not on psychiatric medications, but wanted to be restarted on anti-depressants. It was noted that he was last been seen in a mental health clinic in 2001. He reported depression, low energy and loss of interest. Examination found that his mood was depressed with congruent affect. He was appropriately dressed and well groomed. There were no delusions or hallucinations or suicidal or homicidal ideation. His insight was good and judgment was fair to good. The impressions were depression, not otherwise specified and alcohol abuse in remission. In November 2003, the Veteran was admitted to a VA domiciliary for alcohol use. He denied suicidal or homicidal ideation. Examination found that his skin was warm and dry and no lesions were noted. On February 2004 general medical examination for SSA, examination of the skin was within normal limits, except for tattoos on his arms. On March 1, 2004 examination by a private psychologist on behalf of SSA, the Veteran related that he had no leisure activities or hobbies, and no contact with friends or relatives. Mental status evaluation found that he was well kept. There was some tenseness to his facial expressions. He was somewhat negativistic. He was oriented times four. There was no indication of panic or agoraphobia. The examiner did not determine any anxiety. His depression was moderate to moderately severe. His affect was somewhat flat. He appeared to be anhedonic. The examiner stated that beneath the surface, the Veteran was probably quite hostile. Thought process showed no blocking. His ideas were coherent. He had some suicidal thoughts, but no plans. There was no homicidal ideation. He related that he sometimes hears a voice inside his head speaking to him. His memory was adequate. He did not subscribe to delusions of persecution. He subscribed fairly strongly to indicators of severe depression, but not to somatization. The examiner stated that the Veteran had some kind of depressive condition, and that it was possible that it was a bipolar disorder of a paranoid type. It seemed to be moderately severe. It was possible that some psychotic features were present. VA outpatient treatment records show that in April 2004, the Veteran reported memory loss and feelings of depression for years. He said he had problems sleeping with frequent nightmares. Mental status evaluation found him alert and oriented times four. His dress was neat. Conversation was goal-directed. He denied audio or visual hallucinations and paranoid feelings. He denied suicidal or homicidal ideation. His mood was depressed and his affect constricted. The assessment was major depressive disorder. In June 2004, he complained of problems sleeping with frequent nightmares. He stated that he visited with his neighbors. Mental status evaluation found that he was oriented times four. His conversation was goal-directed. He denied suicidal or homicidal ideation and paranoid feelings. There was no evidence of delusional thinking. His mood was depressed and his affect was restricted. The assessment was major depressive disorder. Similar findings were present in July and August 2004. In January 2005, he stated that he was doing all right with his current medications. Mental status evaluation found that he was oriented times four. His affect was appropriately reactive and mood was “a little worried.” Thought process was relevant and goal-directed. He denied suicidal or homicidal ideation. There was no evidence of a thought disturbance, and no anxiety. The assessments were major depressive disorder and alcohol abuse. In March 2005, he was seen for chest pain and suicidal ideation. He was alert and oriented times three. His speech was coherent and logical. There was no suicidal or homicidal ideation. The diagnostic impression was depression (questionable suicidal ideation). The Veteran said that his episodes of chest pain caused him to feel as if he wanted to die, but he explicitly stated he did not have any suicidal thoughts. Additional VA outpatient treatment records show that in July 2005, the Veteran stated that he had severe anxiety and that he received little benefit from his medication. Mental status evaluation found that his mood was moderately anxious with congruent affect. His thought process was linear. He was appropriately groomed. There were no delusions of hallucinations or suicidal or homicidal ideation. His insight was good and judgment was fair to good. The assessment was anxiety and depressive disorders, not otherwise specified. In December 2005, he said that he had some generalized anxiety and problems with sleep initiation. Mental status evaluation found that his mood was moderately anxious with congruent affect. His thought process was linear. He was appropriately groomed. There were no delusions or hallucinations or suicidal or homicidal ideation. Insight was good and judgment fair to good. In April 2006, he stated that his sleep was improved with medication. Findings similar to those in December 2005 were noted. In May 2006, examination of the skin showed a multiple purpuric rash, possibly from medication. In July 2006, the Veteran felt sad over the loss of a relationship with his girlfriend. In March 2007, he denied significant problems with anxiety or depression. Mental status evaluation found that his mood fairly good, with congruent affect. He was appropriately groomed. Thought process was linear. There were no delusions or hallucinations or suicidal or homicidal ideation. Insight was good and judgment was fair to good. On June 18, 2007 VA psychiatric examination, the Veteran stated that he had nightmares if he did not take his meds. It was noted that he was very argumentative during the interview. Mental status evaluation found that he was alert, but had to be redirected frequently. He was very focused on his medical complaints and complaints against the VA. His grooming was adequate. His eye contact was fleeting. His mood was anxious, but his affect did not appear to be congruent with anxiety. He was somewhat irritable. He was oriented times three. His insight was poor and social judgment was functional. He denied suicidal or homicidal ideation and denied symptoms of a perceptual disorder. The diagnoses were anxiety disorder, not otherwise specified, alcohol dependence and personality disorder, not otherwise specified with paranoid and antisocial features. It was noted that the Veteran was very difficult to evaluate due to his excessive focus on medical problems and his discontent with VA treatment. When asked very specific questions about his psychiatric problems, he typically provided very vague answers. On August 2007 VA general medical examination, the Veteran stated that he gets lesions like pimples and that he uses a cream as needed. His symptoms included itching, but he had no systemic symptoms. Examination of the skin found hypopigmented and patchy areas of erythematous lesions on the anterior portion of his right knee. This involved 0 percent of exposed areas and less than 1 percent of his entire body was affected. No other lesions were noted. The impression was skin rash-dermatitis. VA outpatient treatment records show that in July 2007, the Veteran stated that his twin brother, with whom he was close, had died in June. Mental status evaluation found that his mood was slightly anxious with congruent affect. His thought process was linear. He was appropriately groomed. There were no delusions or hallucinations, and no suicidal or homicidal ideation. Insight and judgment were good. In November 2007, he stated that his mood and anxiety remained low. Examination found that he was oriented times four. His thought process was clear and logical. There was no suicidal or homicidal ideation or perceptual disturbances. His mood was a little depressed and his affect was euthymic. His memory was intact. Judgement was good. The diagnoses were anxiety and depressive disorders, not otherwise specified. In August 2008, he stated that his mood was a bit worse. The findings were similar to those in November 2007. On February 2009 VA examination, the Veteran reported that he had had a chronic rash until 1993 when he underwent a desensitization program. He stated that he had not received any treatment for a rash in the previous year. Examination of the skin found that it was warm and dry with good color. There was no atrophic skin. There was no rash on the Veteran's face, trunk, arms or legs. The diagnosis was no evidence of a skin rash. On March 2009 VA psychiatric examination, the Veteran stated that he was frustrated with VA. He noted that he had one friend and did not associate with a lot of people. Mental status evaluation found that he was well groomed. His speech was pressured. His mood appeared hypomanic and irritable with a constricted affect. There was no suicidal or homicidal ideation, hallucinations or delusions. Attention, memory and judgment appeared to be within normal limits. The diagnostic impressions were bipolar disorder, not otherwise specified; anxiety disorder, not otherwise specified; and personality disorder, not otherwise specified, provisional. It was noted that the Veteran reported difficulty adapting to stressful circumstances and an inability to establish and maintain effective relationships. He noted that the symptoms would likely cause significant occupational impairment. VA outpatient treatment records show that in June 2009, the Veteran stated that his mood was mostly stable. Mental status evaluation found his grooming was good. Speech was normal in tone, and thought processes were clear, logical, linear and goal-directed. There was no suicidal or homicidal ideation or perceptual disturbances. His mood was ok and affect euthymic. Judgment was good. The diagnoses were depression and anxiety. In December 2009, the Veteran said his anxiety level was high. Mental status evaluation found that grooming was good. He was oriented times four. Thought process was clear and logical. There was no suicidal or homicidal ideation or perceptual disturbances. His mood was a little anxious and his affect was euthymic. His memory was intact. Judgment was good. In April 2010, he reported some increased anxiety and that he felt on edge. Mental status evaluation found that his mood was anxious with congruent affect. Thought process could be circumstantial. He was appropriately groomed. There were no delusions or hallucinations, and no suicidal or homicidal ideation. Insight and judgment were good. The assessments were anxiety disorder and depressive disorder, not otherwise specified. In March 2011, the Veteran reported significant anxiety despite medication. Mental status evaluation found that his mood was anxious with congruent affect. His thought process could be circumstantial. He was appropriately groomed. He had no hallucinations or delusions and there was no suicidal or homicidal ideation. Insight and judgment were good. On March 2011 VA Persian Gulf examination, the Veteran stated he had red bumps on his arms, legs and trunk after his return from Saudi Arabia, but had not had a recurrence since 1993. He had no symptoms at that time, and had not received treatment in the previous year. Examination of the skin found it was warm and dry and had good color. There was no evidence of red bumps or any small bumps. The diagnosis was no evidence of skin rash. On August 2011 VA examination, the Veteran stated that he sometimes has skin lesions on his arms, legs, stomach, chest and back. It was noted that the skin condition did not cause scarring or disfigurement of the head, face or neck. He had not had any debilitating or non-debilitating episodes in the previous 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme or toxic epidermal necrolysis. Examination found no dermatitis involving exposed or non-exposed areas. There was one lesion over the thigh. The Veteran had scattered minimal macular lesions measuring 0.5 centimeters by 0.5 centimeters over the lower part of both legs and the back of the chest. The diagnosis was dermatitis. On November 2011 VA psychiatric examination, the Veteran stated that he was receiving treatment for anxiety and a depressive disorder. He said that he prefers being by himself and does not have faith in people. His symptoms included depressed mood, anxiety, suspiciousness and chronic sleep impairment. He did not have panic attacks, memory loss, flattened affect, impaired judgment, suicidal ideation or obsessional rituals. The examiner noted that the Veteran was difficult to interview since he was vague in answering questions and went off on tangents. The results of the mental status evaluation were otherwise unremarkable. The diagnoses were alcohol abuse, malingering or psychiatric and physical symptoms, personality disorder, not otherwise specified with borderline features. It was noted that there was no objective evidence to support the symptoms or diagnosis of an Axis I mood disorder. Based on test results, there was significant evidence that the Veteran was malingering. On November 2011 VA skin examination, it was noted that the Veteran had an intermittent rash. He had been treated with antihistamines and topical corticosteroids for six weeks or more but not constantly. He had not had debilitating or non-debilitating episodes in the previous 12 months. Examination noted that dermatitis did not involve an exposed area. The diagnosis was dermatitis. On January 2012 VA psychiatric examination, the Veteran's symptoms included depressed mood, anxiety, suspiciousness and chronic sleep impairment. He did not have panic attacks; flattened affect; memory loss; circumstantial, circumlocutory or stereotyped speech; impaired judgment; disturbances of mood and motivation; difficulty in establishing and maintaining effective work and social relationships; suicidal ideation, obsessional rituals; persistent delusions or hallucinations; spatial disorientation; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living. The diagnoses were alcohol abuse, malingering or psychiatric and physical symptoms, personality disorder, not otherwise specified with borderline features. The examiner stated that a mental disorder had been formally diagnosed, but the symptoms were not severe enough to interfere with occupational and social functioning or to require continuous medication. On August 23, 2012 VA psychiatric examination, the Veteran stated that he was by himself except for when he went to church. His symptoms included depressed mood, anxiety; circumstantial, circumlocutory or stereotyped speech; speech intermittently illogical, obscure or irrelevant; disturbances of mood or motivation; difficulty in establishing and maintaining effective work and social relationships. He did not have suspiciousness; panic attacks; memory loss; chronic sleep impairment; flattened affect; impaired judgment; gross impairment of thought processes; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; suicidal ideation; obsessional rituals; impaired impulse control; spatial disorientation; persistent delusions or hallucinations; neglect of personal appearance, intermittent inability to perform activities of daily living; and disorientation to time or place. The diagnoses were anxiety disorder, depressive disorder, not otherwise specified, history of polysubstance abuse; and personality disorder, not otherwise specified. The examiner stated that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. VA outpatient treatment records show that in April 2012, the Veteran stated that he had a rash that waxed and waned. He said the medication he was taking did not help. Examination found excoriated dermatitic eruptions on his lower back and upper chest. In June 2012, it was noted that there was some erythematous dermatitis on his left anterior shoulder and lower back. The diagnosis was eczema. In November 2012, it was noted that he had an excoriated eruption on his lower back and upper chest. In January 2013, the Veteran denied a significant problem with depression. Mental status evaluation found that his mood was anxious with a congruent affect. His thought process could be tangential. He was appropriately groomed. There were no delusions or hallucinations and no suicidal or homicidal ideation. Insight and judgment were good. In June 2013, he reported generalized anxiety. Mental status evaluation findings were similar to those in January 2013. In July 2013, he stated that he had a rash covering much of his body that had been present for a few months and he did not get any help from anti-scabetic treatment. Examination found superficial ulcers covering most of his body. The spacing between lesions was roughly the same for all lesions. There were no lesions from the neck up, on the anterior pelvis or genitalia. VA outpatient treatment records show that in August 2013, the Veteran was noted to be extremely restless and on edge. His grooming and hygiene were fair to poor. His speech was extremely rapid and tangential. His mood was anxious and his affect congruent. He was oriented times four. Thought process was mildly tangential. Thought content was marked by concern about his health and reporting on his pain. There was no evidence of hallucinations or delusions. His memory appeared intact. Insight and judgment and impulse control appeared greatly impacted by anxiety. He denied active or passive thoughts of harming himself or others. In September 2013, mental status evaluation found that his mood was anxious and mildly dysphoric with a congruent affect. Thought process could be tangential. He was appropriately dressed and groomed. There was some possible paranoia. There were no delusions or hallucinations and no suicidal or homicidal ideation. Insight and judgment were good. The diagnoses were anxiety disorder and depressive disorder, not otherwise specified. Also in September 2013, it was noted that the Veteran had superficial ulcers on his arms and legs. The diagnosis was excoriations. In December 2013, he complained of some dysphoria and irritability. He exhibited some flight of ideas and admitted to some racing thoughts, but denied experiencing an elevated mood. Mental status evaluation found that his mood was anxious and mildly dysphoric with congruent affect. Thought process could be tangential. He was appropriately dressed and groomed. There was some possible paranoia. There were no delusions or hallucinations and no suicidal or homicidal ideation. Insight and judgment were good. In January 2014, a VA physician contacted the Veteran at the recommendation of a counselor at a Vet Center who said the Veteran might be experiencing delusional thinking. It was noted that he described some probable paranoia, but it was noted that he did not appear to be acting on his psychosis in a dangerous manner. On October 21, 2015 VA psychiatric examination, the Veteran stated that he lived a lonely life as others were not able to tolerate him. He said he felt suicidal many times, but his faith helped him to not do anything. The diagnoses were schizoaffective disorder, bipolar type, other specified trauma and stressor related disorder, and personality disorder, by history. The examiner stated that the Veteran had total occupational and social impairment. The psychiatric disability has been rated 100 percent from the October 21, 2015 examination date. On April 14, 2016 VA skin examination, the Veteran stated that he continued to have itching of the skin. He reported that he had episodic rashes on his body. He noted that when the rash is present, it usually affects his entire body, except for his genitals. He only used over-the-counter medication, and had not seen a dermatologist since 2013. It was noted that there was no scarring or disfigurement of the head, face or neck. There were no systemic manifestations of any skin disease. He reported less than six weeks of treatment in the previous 12 months, and said he used Benadryl for itching. No other treatment was reported. He had not had any debilitating or non-debilitating episodes in the previous 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme or toxic epidermal necrolysis. Examination found no rashes were present. There were no scabs, erythema or hives. The diagnosis was dermatitis. On July 2016 VA skin examination, the Veteran reported his skin rash was stable. He stated that he might have occasional itching, but there had been no significant change in his skin condition in years. The skin condition did not result in scarring or disfigurement of the head, face or neck. There were no systemic manifestations due to skin disease. The Veteran had not been treated with oral or topical meds in the previous 12 months. He had not had any debilitating or non-debilitating episodes in the previous 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme or toxic epidermal necrolysis. Examination found that he had dermatitis involving less than five percent of his total body area, none involving an exposed area. It was noted that he had dermatitis only on both arms. The diagnosis was dermatitis. Increased Ratings Disability ratings are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Reasonable doubt regarding the degree of disability is to be resolved in favor of the claimant, 38 C.F.R. § 4.3. Functional impairment is to be assessed on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When the appeal is from the initial rating assigned with an award of service connection, separate ratings can be assigned for separate periods of time based on the facts found – a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999). As is noted above, the matters of the ratings for the Veteran’s service-connected psychiatric and skin disabilities cover an extended period of time. There are many periods for which few medical records are available. 1. Staged increased ratings of 50 percent from March 1, 2004 and 70 percent from August 23, 2012 are granted for other specified trauma and stressor-related disorder. On and after February 3, 1988, the Schedule for Rating Disabilities was amended to read as follows: A 100 percent rating is warranted when the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic, symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. Demonstrably unable to obtain or retain employment. A 70 percent rating is warranted when the ability to establish and maintain effective or favorable relationships with people is severely impaired. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 50 percent rating is warranted when the ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 30 percent rating is warranted when there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people. The psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. A 10 percent rating is warranted when less than criteria for the 30 percent, with emotional tension or other evidence of anxiety productive of mild social and industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (as in effect February 3, 1988). Words such as “mild”, “considerable” and “severe” were not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. 4.6 (2010). It should also be noted that use of terminology such as “mild” by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2010). With respect to the word “definite”, as the Court pointed out in Hood v. Brown, 4 Vet. App. 301, 303 (1993), that term is qualitative rather than quantitative. However, it is possible to quantify the degree of impairment which would lead to an award at the 30 percent level. Cox v. Brown, 6 Vet. App. 459, 461 (1994). In a precedent opinion, dated November 9, 1993, the General Counsel of the VA concluded that “definite” is to be construed as “distinct, unambiguous, and moderately large in degree.” It represents a degree of social and industrial inadaptability that is “more than moderate but less than rather large.” VAOPGCPREC 9-93 (Nov. 9, 1993). The purpose of the 1988 change in the VA Schedule for Rating Disabilities was to provide consistency in describing social and industrial impairment in each of the categories of mental disabilities. VAOPGCPREC 7-89 (March 8, 1989). The effect of the change was that the new rating criteria were more favorable to appellants. See Clark v. Derwinski, 2 Vet. App. 166, 169 (1992): “... the new rating criteria are most favorable to appellant.” On and after November 7, 1996, the Schedule for Rating Disabilities was again amended. The pertinent provision now reads as follows A 100 percent rating is warranted for a psychiatric disability 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. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent rating is warranted if 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 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Code 9411. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), CAVC noted that the list of symptoms in the Board’s general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather is to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. It was noted the regulation requires an evaluation of the effects of the symptoms, and not a search for a set of particular symptoms. Regarding the rating prior to September 18, 2007, on February 1993 VA psychiatric examination, the Veteran was noted to be a heavy drinker. Mental status evaluation found that his affect somewhat blunted, and he reported memory problems. He was well oriented. VA outpatient treatment records from 1994 to 2003 show that his mood was variously described as dysphoric or depressed with a flat or labile affect. At times, he was irritable or angry. He was generally fully oriented. When he was seen in November 2003, it was noted that he was not taking any psychiatric medications, though he requested that they be resumed. He had not been seen in the mental health clinic for about two years. The clinical record pertaining to the status of the Veteran’s psychiatric disability prior to March 1, 2004 is rather sparse, and the evidence it provides does not support that a rating in excess of 10 percent was warranted prior to that date. It shows that prior to November 2003 he was not on psychiatric medication and was not receiving regular treatment (suggesting he was functioning adequately); thus, more than mild disability was not shown. The findings on examination by a private psychologist on March 1, 2004 provide the first detailed description of psychiatric symptoms and impairment warranting an increased rating. The examiner noted the Veteran’s reports of some suicidal thoughts and heard voices, and found the Veteran's depression was moderate to moderately severe. Such findings reasonably reflect psychiatric disability productive of reduced reliability and productivity (warranting a 50 percent rating). Subsequent VA outpatient records and the June 2007, March 2009, November 2011 and January 2012 VA psychiatric examination contain findings that confirm the 50 percent rating, but no higher, is warranted. The June 2007 VA examination found the Veteran, anxious, irritable, and having poor insight. On March 2009 VA examination, it was noted that the Veteran had difficulty adapting to stressful circumstances. However, deficiencies in most areas were not shown. The Veteran was apparently tending to activities of daily living on his own. On November 2011 and January 2012 VA examinations, panic attacks, obsessional rituals, suicidal or homicidal ideation, or audio or visual hallucinations were not noted. Thus, prior to August 23, 2012 deficiencies in most areas were not shown, and a rating in excess of 50 percent was not warranted. The findings VA psychiatric examination on the August 23, 2012 support the award of a 70 percent rating from the examination date. The examiner specifically found that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment and thinking and/or mood. However, it was not until an October 21, 2015 VA psychiatric examination that an examiner found the Veteran's psychiatric disability productive of total occupational and social impairment. Symptoms of a severity warranting a 100 percent schedular rating were not shown prior to the October 21, 2015 examination date, and a 100 percent rating was not warranted prior to that date. 2. Entitlement to increases in the (0 percent prior to October 12, 2011, 30 percent prior to April 14, 2016, and 0 percent from that date) for dermatitis During the course of this appeal, VA issued new regulations for the evaluation of skin disabilities, effective August 30, 2002. See 67 Fed. Reg. 49590-49599 (July 31, 2002). Accordingly, the Board will review both the rating criteria in effect prior to August 30, 2002 and the criteria which became effective on that date to determine the proper evaluation for the Veteran’s scars. However, the amended rating criteria can be applied only for periods from and after the effective date of that regulatory change. See VAOPGCPREC 3-00. A 50 percent evaluation may be assigned for eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. A 30 percent rating may be assigned for exudation or itching constant, extensive lesions, or marked disfigurement. A 10 percent evaluation may be assigned with exfoliation, exudation or itching, if involving an exposed surface or extensive area. 38 C.F.R. § 4.118, Diagnostic Code 7806 (as in effect prior to August 30, 2002). A 60 percent evaluation is warranted for eczema with more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, with constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. With 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as with corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, a 30 percent evaluation is warranted. With at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; with intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, a 10 percent rating is warranted. 38 C.F.R. § 4.118, Code 7806. Regarding the rating prior to October 12, 2011, there are few clinical records pertaining to the extent of the Veteran's dermatitis, particularly from 1993 until 2007. He was noted to have a stomach rash in August 1994 and atopic dermatitis in September 1994. A February 2004 examination for SSA showed his skin to be normal. On August 2007 VA examination, he reported use of a topical cream for his lesions on an as needed basis. He described some itching, but there were no systemic symptoms. The only area of involvement was on the right knee, and the stated that it involved 0 percent of exposed area and 0 percent of the entire body. On February 2009 and March 2011 VA examinations, there was no evidence of a skin rash. Accordingly, the preponderance of the evidence is against the award of a compensable rating for dermatitis prior to October 12, 2011. It was not until the November 2011 VA examination that the Veteran noted he treated his skin condition with antihistamines and a topical steroid. He reported treatment for six weeks but not constantly. To warrant the next higher (60 percent) rating, the evidence must show involvement of more than 40 percent of the entire body or exposed areas or that constant or near-constant treatment is required. Considering the Veteran’s own reports regarding the nature and frequency of treatment received, and that there was no indication that the dermatitis involved such more than 40percent of total body or exposed areas, a rating in excess of 30 percent for the period is not warranted. Based on the findings on the April 14, 2016 VA examination, the RO assigned a 0 percent rating from the examination date. On that examination Veteran reported use of over-the-counter topical medication for less than six weeks. It was noted that examination found no rashes. Similar findings were reported on July 2016 VA examination. Notably, the Veteran stated he had not been treated for dermatitis with oral or topical medication. The examiner stated that less than five percent of the total body area was affected. Accordingly, from April 14, 2016, the preponderance of the evidence is against an award of a compensable rating for the dermatitis. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James R. Siegel, Counsel