Citation Nr: 0005931 Decision Date: 03/06/00 Archive Date: 03/14/00 DOCKET NO. 93-05 311 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased rating for Raynaud's phenomenon of the hands and feet, currently evaluated as 50 percent disabling. 2. The propriety of the initial 50 percent rating assigned for service-connected post traumatic stress disorder (PTSD) from November 27, 1990. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD J. A. Markey, Counsel INTRODUCTION The veteran served on active duty from July 1964 to September 1971. This matter came before the Board of Veterans' Appeals (Board) from an October 1990 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that denied the veteran's claim for an increased evaluation for his service-connected Raynaud's phenomenon of the hands and feet. A notice of disagreement was received in December 1990. A statement of the case was issued in January 1991. A substantive appeal was received from the veteran in February 1991. A hearing was held at the RO in May 1991. In December 1994 and again in June 1999, this claim was remanded to the RO for further development. In March 1995, the veteran's claims folders were transferred to the RO in Jackson, Mississippi. This matter also came before the Board from a January 1999 decision by the (Jackson, Mississippi) RO that established service connection for PTSD. In the June 1999 remand, the Board construed an April 1999 informal hearing presentation as, in part, a notice of disagreement with respect to this decision. A statement of the case was issued in September 1999. The Board construes a VA Form 646 dated in December 1999 to be a substantive appeal. The Board notes that the RO adjudicated the claim involving PTSD as one for an increased rating. However, the veteran's appeal involves the initial evaluation assigned following the grant of service connection for this disorder. Hence, the Board has re-characterized the issue in light of the distinction noted by the United States Court of Appeals for Veterans Claims (Court) in the decision Fenderson v. West, 12 Vet. App. 119 (1999). Furthermore, inasmuch as a higher evaluation is available for this condition, and the veteran is presumed to seek the maximum available benefit for a disability, the claim remains viable on appeal. Id.; AB v. Brown, 6 Vet. App. 35, 38 (1993). Finally, in the June 1999 remand, the Board noted that in an October 1998 decision, the RO found that there was no clear and unmistakable error in an April 1982 decision which did not assign an evaluation higher than 50 percent for the service-connected Raynaud's phenomenon of the hands and feet. The Board construed written argument dated in March 1999 to be a notice of disagreement, and remanded this issue for the issuance of a statement of the case. Accordingly, statement of the case was issued in July 1999. However, the veteran has not perfected an appeal of this claim by the filing of a timely substantive appeal. As such, this claim is not before the Board. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable resolution of the veteran's claims on appeal has been obtained by the RO. 2. Since September 1990, the veteran's Raynaud's phenomenon of the hands and feet has been manifested by coldness, but with no ulceration, and subjective complaints of changes in pigmentation, and numbness. 3. Since the effective date of the grant of service connection in November 1990, the veteran's PTSD has primarily been manifested by nightmares, depression, flashbacks, sleep disturbance, and anxiety. 4. The service-connected PTSD results in no more than considerable industrial and social impairment, or, since November 7, 1996, considerable difficulty in establishing and maintaining effective work and social relationships; there is no showing of 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 work-like setting); and inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. An evaluation in excess of 50 percent for the appellant's Raynaud's phenomenon of the hands and feet is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.104, Diagnostic Code 7117 (1999); 38 C.F.R. § 4.104, Diagnostic Code 7117 (1997). 2 As the initial 50 percent evaluation assigned for the veteran's service-connected PTSD was proper, the criteria for a higher evaluation are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (1999); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION Introduction As a preliminary matter, the Board finds that these claims on appeal are plausible and capable of substantiation and are therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). The Board also is satisfied that all relevant facts have been properly developed and no further assistance to the veteran is required in order to comply with the duty to assist. Id. I. Entitlement to an increased rating for Raynaud's phenomenon of the hands and feet, currently evaluated as 50 percent disabling. Background For historical purposes, it is noted that in December 1971, the RO established service connection for Raynaud's phenomenon of the hands, symptomatic, based on a review of the veteran's service medical records which indicated that he suffered a frozen hand injury, was given a limited profile for weather conditions on several occasions, and that Raynaud's phenomenon of the hands was noted. This decision was also based on the report of a contemporaneous VA examination which noted the veteran's complaints of an inability to endure temperatures below 45 degrees, aching, some discoloration, and whiteness of the palms, as well as a diagnosis of Raynaud's phenomenon of the hands, symptomatic. Based on these findings, a 20 percent evaluation was assigned for this disorder. In a June 1978 decision, the RO increased the evaluation assigned for this disorder to 40 percent, chiefly based on the findings documented in a June 1978 VA examination report, including that the veteran's hands were found to be cool and that during short periods of time there were variable areas of blanching and flushing observed over the palms. A diagnosis of progressive, moderately severe Raynaud's disease of the hands was noted on this report. In an April 1982 decision, the RO increased the evaluation assigned for this disorder, now characterized as Raynaud's phenomenon of the hands and feet, to 50 percent, based in part on the review of an April 1981 private medical record which documented involvement of both the veteran's hands and feet, to include that the hands were cool without discoloration or ulcers, that the feet were cool, and that studies showed decreased blood flow to the fingers and toes. It appears that the report of a September 1990 VA examination was treated as an informal claim for an increased evaluation for the service-connected Raynaud's phenomenon of the hands and feet. This claim was denied by the currently appealed October 1990 RO decision. The relevant evidence of record includes the September 1990 VA examination as well as the reports of additional examinations and the veteran's testimony given during a May 1991 RO hearing. The September 1990 VA examination report indicates that the veteran gave a history of suffering from Raynaud's phenomenon of the hands and feet since July 1964, and that the disorder had worsened over the years. He reported that his hands were cold and that he was unable to tell if he was touching anything. The veteran also noted a loss of feeling in his feet and hands, but it was noted that he could feel touch, pin prick, and pressure on both hands and feet. The veteran claimed that his hands and feet turned purple when the weather was cold, and that his toes occasionally cramp. The examiner noted that he could not feel any pulses in the veteran's feet, that the feet were slightly cooler than the hands, and that he could feel a radial pulse in both wrists. During the RO hearing, the veteran testified that numbness, pain, and circulation in his hands and feet were getting worse. He noted that he experienced joint pain, and arm and leg fatigue, on a daily basis. The veteran further testified that he occasionally got a rash, and experienced numbness and cramping in his arms and legs. He noted that on two or three occasions during the winter months he got sores between his toes but that they cleared up before he was able to be examined by the VA. He noted that he got blisters on a couple of occasions during the summer months, and that on these occasions (winter and summer), numbness increased in the toes, they turned a light purple color, and then white, and that they got cold. He further noted that he had never had ulcers about his hands, but had injured them unknowingly when he hit something and did not feel anything . The veteran's spouse testified that the veteran's hands and feet were cold to the touch, and that he suffered from muscle and joint pain. She noted that occasionally the veteran's skin got ashy, cracked, and bled, especially when it got cold. The veteran was examined by Ben W. Cheney, M.D. in May 1994. The report of this examination indicates that he was shot in the left foot in September 1993 when he was robbed (the Board notes that medical evidence of record, including from VA, confirm this incident), and presented with complaints of left foot problems and problems surrounding his Raynaud's disease. Physical examination of the extremities revealed no clubbing, cyanosis, or edema, but did show evidence of the gunshot wound between the left great toe and second toe. A VA general examination was accomplished in February 1998, the report of which documents the veteran's history of Raynaud's phenomenon, including an inservice cold injury, and that the veteran indicated that over the years he has had symptoms of this disorder in both the winter an summer. The veteran noted that in the summer, exposure to an air conditioned room produces a cycle of pallor or rubor, and pain, and that things such as holding a glass containing a cold drink or being exposed to cold environmental temperatures could also initiate this cycle. He noted that he has tried sleeping in gloves and socks to alleviate the symptoms but has had limited success, and he complained of markedly decreased sensation in his hands resulting in a tendency to be unaware of injuries to his hands. On examination, the veteran's skin was unremarkable other than the existence multiple scars and that the hands and feet were cold to the touch. There was tenderness about the veteran's left foot, secondary to the gunshot wound. As a result of this examination, the veteran was diagnosed with, among other things, moderately severe Raynaud's disease involving of the hands and feet. The examiner commented that during the examination, he or she was able to observe the cycle of changes in the Raynaud's phenomenon in the veteran's hands, and to a lesser extent, his feet. A VA cold injuries examination was accomplished in March 1998 by the same examiner who conducted the February 1998 general examination. The veteran's history was again noted, as were most of the veteran's complaints documented above. During this examination, the veteran added that he often awakens due to symptoms of the Raynaud's phenomenon or cramps in his legs, and that his feet and hands are cold year round. He noted that episodes of the Raynaud's phenomenon vary in frequency, in that they tend to occur on a daily basis during the cold season and occur three to four times a week during the summer. On examination, the veteran's skin was found to be normal in color and unremarkable, except for the hands and feet, which were cold to the touch. The veteran's hands were also noted to be dry with multiple scars, but with no ulceration. As a result of this examination, the veteran was diagnosed with moderately severe Raynaud's phenomenon involving the hands and feet, secondary to a cold injury. The examiner commented that during the examination, as was the case during the March 1998 examination, he or she was able to observe the cycle of changes in the Raynaud's phenomenon in the veteran's hands, and to a lesser extent, his feet, and that the findings of Raynaud's phenomenon were "classic." Analysis Essentially, it is maintained that the evaluation currently assigned for the veteran's service-connected Raynaud's phenomenon of the hands and feet is not adequate, given the current symptomatology of this disorder. In this regard, it is pointed out that disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § Part 4. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (1999). The Board has reviewed the veteran's claim in light of the history of the disability since its onset; however, where, as in this case, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that, during the course of this appeal, the veteran's service-connected Raynaud's phenomenon of the hands and feet has been rated as 50 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7117. The Board also notes that by regulatory amendment, effective on January 12, 1998, substantive changes were made to the schedular criteria for evaluating cardiovascular disorders, including Raynaud's syndrome, and that where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). As reflected in the December 1999 supplemental statement of the case, the RO has considered both the former and the revised applicable criteria; hence, there is no due process bar to the Board doing likewise, and applying the more favorable result. See Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993). That said, the Board points out that consideration will be given to the effective date of the revised regulation. In other words, for any date prior to January 12, 1998, the Board will not apply the revised rating schedule to the claim, but from that date onward the Board will apply both the former and revised criteria. Prior to January 12, 1998, a 20 percent evaluation was appropriate for Raynaud's disease with occasional attacks of blanching or flushing; a 40 percent evaluation required frequent vasomotor disturbances characterized by blanching, rubor and cyanosis; and a 60 percent evaluation required multiple painful, ulcerated areas. As reflected by a note following this criteria, the 20 percent evaluation was applicable to unilateral or bilateral involvement of both upper and lower extremities, and the 40 percent and 60 percent evaluations were applicable to unilateral involvement. Further, with bilateral involvement separately meeting the requirements for evaluation in excess of 20 percent, 10 percent would be added to the evaluation for the more severely affected extremity only, except where the disease had resulted in an amputation. In this case, the resultant amputation rating will be combined with the schedular rating for the other extremity, including the bilateral factor, if applicable. 38 C.F.R. § 4.104, Diagnostic Code 7117 (1997). Under the revised criteria effective January 12, 1998, a 40 percent evaluation is provided for Raynaud's syndrome when there are characteristic attacks occurring at least daily. A 60 percent evaluation is provided when there are two or more digital ulcers and a history of characteristic attacks. 38 C.F.R. § 4.104, Diagnostic Code 7117 (1999). According to the note following these criteria, for purposes of this section, characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias and precipitated by exposure to cold or by emotional upsets. Further, the note dictates that these evaluations are for the disease as a whole, regardless of the number of extremities involved or whether the nose and ears are involved. In this case, the evidence reflects that prior to January 1998, the veteran complained of numbness and coldness of his hands and feet, and pigmentation changes, and that the cold symptoms were demonstrated on VA examination (September 1990). However, pigmentation changes were not medically indicated, nor was there any indication that the veteran's various other complaints - such as cramping and fatigue - were related to his service-connected Raynaud's phenomenon of the hands and feet. This medical evidence also did not indicate that there were any ulcerated areas about the veteran's hands or feet. As noted, under the old rating criteria, a 40 percent rating was assigned if a single extremity was involved to the required degree, but only an additional 10 percent could be added, even if all the other extremities were involved to a similar degree (that standard was made clearer by the recently revised rating criteria which clearly state that the rating is on the basis of the overall condition, regardless of the number of extremities involved). In this case, it is clear that no more than a 50 percent evaluation was warranted under the old criteria prior to January 12, 1998; in fact, in the Board's opinion, this 50 percent evaluation would have been primarily based on the subjective complaints made by the veteran, and not on objective medical evidence. In other words, a 40 percent evaluation is warranted based on the veteran's complaints of, essentially, frequent vasomotor disturbances characterized as blanching and cyanosis, with 10 percent added due to bilateral involvements (of the feet and hands). Regarding the evidence dated subsequent to the regulation change, the Board notes that under the revised criteria, it is clear that the veteran does not meet the criteria for a 60 percent evaluation, because while the veteran made references to occasional sores and blisters during the RO hearing, none of the medical evidence of record reflects that the veteran's Raynaud's phenomenon of the hands and feet is manifested by any digital ulcers. It is noted that there is no 50 percent rating currently listed under Diagnostic Code 7117. Under the circumstances (i.e. that there are no areas of ulceration about the hands or feet shown), the Board is also unable to conclude that an evaluation in excess of 50 percent would be warranted during this more recent time frame under the provisions of Diagnostic Code 7117 that were in effect prior to January 1998. The Board does note that at this point it appears that the 50 percent evaluation is medically supported by the evidence. Specifically, the examiner who recently evaluated this disorder was able to observe the "cycle of changes" (described by the veteran to include pallor or rubor) in the veteran's Raynaud's phenomenon of the hands and feet. In conclusion, the Board finds that the evidence establishes that the veteran's service connected Raynaud's phenomenon of the hands and feet is no more than 50 percent disabling under either the former or revised applicable schedular criteria. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and an increased rating must be denied. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990). Also, the Board finds, as did the RO, that the evidence of record does not present such an exceptional or unusual disability picture so as to render impractical the application of the regular rating schedule standards and to warrant assignment of an increased evaluation for Raynaud's phenomenon of the hands and feet on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (1999). There is absolutely no showing that this disorder has resulted in a marked interference with employment, and there is no indication that it has necessitated frequent periods of hospitalization. In the absence of evidence of such factors, the Board finds that criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v Brown, 8 Vet. App. 218, 227 (1995). II. The propriety of the initial 50 percent rating assigned for service-connected post traumatic stress disorder (PTSD). Background A review of the record reflects that service connection was established for PTSD by the currently appealed January 1999 decision. This decision was based in part on information provided by the veteran - and partially confirmed by the United States Armed Services Center for Research of Unit Records (USASCRUR)) - to the effect that while serving in Vietnam, specifically in Long Binh, the veteran's unit came under attack. This decision was also based on medical evidence that will be discussed below. Based on this medical evidence, a disability evaluation of 50 percent was assigned for this disorder, effective November 27, 1990. The relevant evidence of record pertaining to evaluation of the severity of the veteran's PTSD includes VA outpatient treatment records, examination reports, and private medical records. A VA psychiatric evaluation was accomplished in March 1991, the report of which indicates that the veteran related that he was then unemployed, having last worked as a salesman for cable companies from 1988 to 1990. His complaints included trouble sleeping, nightmares about Vietnam, and sexual difficulties. The veteran also related that he sometimes felt uneasy around others, was overcritical, had no self confidence, was sad, occasionally heard voices, and felt that people were watching him. He further noted that he felt depressed most of the time. The report also indicates that the veteran was married in 1966, and had two children prior to a divorce; and that he was currently married and has had two additional children. The veteran explained that his biggest problem was an inability to hold a job and make his family happy. Intellectual evaluation revealed a startling lack of mathematical ability, but that the veteran was an excellent speaker. A prior arrest was noted to have caused some the veteran's problems in obtaining employment. The examiner noted that the veteran was not a schizophrenic, and that his medication routine did not support significant PTSD. VA records also reflect that the veteran has been followed at the Mental Health Clinic (Clinic) since as early as late 1990. In March 1991 he presented with complaints of family and financial problems, an inability to obtain and maintain employment, nightmares, and flashbacks. In December 1991 he was seen complaining of continued nightmares and night sweats, with periods of anger. In January 1992 he presented with increased stress as his wife had filed for divorce and he was not employed at the time. In June 1992, he presented with continued problems surrounding his divorce proceedings. His affect was noted to be flat, his eye contact good. In May 1993, it was noted that the veteran was "very stressed" and depressed, secondary to divorce proceedings and losing valued relationships. It was also noted that the veteran was articulate and verbal. In June 1993, the veteran presented at the clinic complaining of sleep difficulty, nightmares, cold sweats, and was diagnosed with PTSD. In July 1993, it appears that the veteran added that he was having homicidal tendencies (the record is partially illegible), and was found to be oriented, alert, in contact with reality, anxious, dysphoric, irritable, resentful, and was having difficulty maintaining control of his anger. It was also noted that the veteran's employment options were extremely limited by these manifestations and his inability to maintain appropriate relations with peers and co-workers. A diagnosis of PTSD and bipolar affective disorder was listed on this outpatient treatment record. In September 1993 the veteran presented with numerous psychosocial problems, including his pending divorce, having been recently robbed and shot in the left foot, and having lost his job. He reported experiencing crying episodes five times a week for the past three years, but denied feelings of worthlessness and hopelessness, and problems with concentration. The veteran also denied hallucinations and delusions, but displayed some grandiose behavior, and reported an increase in flashbacks about Vietnam after recently being shot in the foot. Mental status examination conducted at that time found the veteran to be awake, alert, and oriented times four. He was dressed appropriately and was in apparent good hygiene. His speech was pressured, circumstantial, and tangential, but coherent, monotonic, and logical. The veteran was very articulate, made good eye contact throughout the interview, and while he was somewhat grandiose, there was no clear evidence of delusions. His affect was euthymic, his mood depressed. The veteran was diagnosed with bipolar affective disorder and PTSD by history at that time. The veteran was seen in the Clinic in late September 1993, at which time he reported that he was homeless and continued to take medication. The report of a October 1993 psychological evaluation notes that the veteran had been employed in sales since leaving military service, and that he was found to be agitated and spoke rapidly, displayed little insight and lacked attention and concentration. The veteran was oriented to all spheres and did not appear to have a thought disorder. His affect was within normal limits, and he described his mood as "great." He denied suicidal thought but indicated that he could kill someone if pressured. As a result of this evaluation, the veteran was diagnosed with cyclothymia. In late October 1993, the veteran went to the Clinic to obtain medication for his foot injury, was found to be non- psychotic, and was not depressed or anxious. He used flowery language with articulate expressions, and noted that he earned $50,000 per year. The examiner noted that the veteran appeared to be bipolar in an elated phase (the veteran indicated that he was always that way), and noted that the veteran spoke rapidly and expressed his thoughts in a loud and clear tone. In March 1994, the veteran was seen at the Clinic complaining that "the whole world [was] turning against [him]" and that he was unable to obtain employment. He was found to be pressured, poorly organized, suspicious, angry, discouraged, and depressed, but not delusional. His judgment was fair, and he was diagnosed with PTSD and an adjustment disorder. In late March 1994, the veteran was referred to B. Frank Vogel, M.D. with complaints including an inability to sleep, being afraid, not trusting others, and not wanting to be with others. Dr. Vogel noted that the veteran was neatly dressed, was depressed and angry, but was able to control himself most of the time. The veteran's speech was noted to be loud, "complaining," and explosive. The veteran wept as he related various problems, including that he had lost his job. The examiner noted his impression that the veteran exaggerated his symptoms somewhat and added symptoms that were not really present. The veteran's motivation and cooperation were noted to be good. The veteran related the traumatic events experienced while he served in Vietnam, and indicated that he was doing well until he was mugged and shot in the left foot in September 1993. He noted that this attack revived troubling memories of Vietnam, and that he had not worked since September 1993 due to the bullet wound and the emotional problems resulting from it. The veteran noted that he was first married from 1966 to 1974, and again from 1986 to 1992, and that, essentially, the marriages ended due to his bizarre behavior due to nightmares, because his wives were frightened of him, and because of incompatibility. He related that he has had short-term relationships since then of no emotional importance. Regarding daily activities, the veteran related that he lived alone at the time, that he could take care of his personal needs and household chores with some difficulty, and that in the past he liked to fish, hunt, and swim, among other things, but that now he does not engage in these activities. The veteran also noted that he could use the phone, drive, and shop if necessary. Dr. Vogel opined that the functional limitations described were causally related to the veteran's foot disability as well as his anxiety disorder. On mental status examination, the veteran noted that he first experienced flashbacks five to six times per week, but that they have been reduced to twice a week. He noted that he did not trust anyone, that he feels sad and dejected most of the time, and that he cries once a week. He further noted that his appetite was poor, and that he had suicidal thoughts twice a month but without a plan. He reported a fear of thunder and lightning and a mild phobia of driving over bridges. The examiner noted that the veteran's reported hallucinations did not appear valid. The examiner also related that the veteran was definitely an angry individual who expressed his anger at society and various institutions. Further, he tested the veteran and determined that he was of average intelligence but with a high level vocabulary. The examiner pointed out that the veteran had probably become addicted to Xanax, which he noted was an anxiolytic not widely used in treating severe and chronic anxiety disorders. As a result of this examination, the veteran was diagnosed with PTSD and possible addiction to Xanax, among other things. A Global Assessment of Functioning (GAF) score of 41 was noted. In November 1994, the veteran was seen at the Clinic and indicated that he had been taking Valium for years for depression and that reducing his intake caused anxiety. The veteran was seen on several occasions in 1995 and 1996 for refills of Valium, and it is noted in these records that he was trying to reduce his dosage amounts. In April 1996, the veteran was seen by a VA psychologist, at which time he gave a history of witnessing traumatic events in service, and of experiencing numerous post-service traumatic events, including being robbed and shot in the foot. The veteran indicated that he had not worked since the robbery and that he lived with his fiancée. The examiner noted that the veteran appeared alert and oriented times three, and that his mood was depressed and his affect appropriate to his mood. A diagnosis was deferred. A few days later in April 1996 the veteran was seen at the Clinic complaining of severe and incapacitating anxiety and that his Valium dosage had been reduced. On examination, the veteran was found to be stable with no suicidal or homicidal ideation, and no psychosis. He was diagnosed with a generalized anxiety disorder. In May 1996, the veteran presented with complaints of feeling depressed and overwhelmed at times, but noted that he could "handle it." He requested refills of his various medications, including Valium. The veteran denied suicidal ideation, stated that he was unable to work but noted that he did odd jobs. In June 1996, the veteran was seen by a VA psychologist, at which time he noted that he had been unemployed since 1981, and again related the traumatic events experienced during and after his military service. The veteran complained of anxiety, depression, anger control problems, sleep disturbance, and intrusive memories. Objective findings included a depressed mood, anger and irritability, with no suicidal or homicidal ideation, and no psychosis. The veteran was assessed with PTSD. It appears from the records that the veteran began attending PTSD group therapy that month. VA outpatient treatment records further reflect that the veteran was seen in September 1996 and reported that his depression had increased; he noted that he had been having problems with anxiety and increased his medication intake. A depressed mood was noted, as was a labile affect; it was noted that the veteran was not psychotic. A diagnosis of PTSD was indicated. A depressed mood and flat affect were noted in December 1996 and March 1997, the latter report noting the veteran's complaints of high anxiety and problems with his separated girlfriend. In August 1997, the veteran noted that he was having family problems and that he had been extremely anxious. A VA general medical examination was accomplished in February 1998, the report of which indicates that the veteran was previously diagnosed with PTSD, and that prior to the September 1993 robbery, he experienced poor anger control, difficulty in his interpersonal relationships, and intrusive dreams about the events experienced in Vietnam. Subsequent to September 1993, these dreams included the experience of being shot and robbed. On psychiatric evaluation, the veteran was found to be oriented to time, place, and person, and his responses to questions were appropriate. The veteran was diagnosed with PTSD, among other disabilities. A VA psychiatric examination was accomplished in April 1998, the report of which reiterates the veteran's history of service in Vietnam and of having been robbed and shot in the left foot. It was noted that the veteran last worked in 1993, that he has had poor results from treatment, has had such difficulty walking that he has to use a cane, and that this causes him a great deal of pain. His history of two prior marriages was noted, and it was noted that he has been in a relationship - described as "promising" - for the past three years, and that he has a six month old daughter. On mental status evaluation, it was noted that the veteran was alert and helpful, and showed no memory problems in detailing his military and civilian history. The veteran indicated that he did not discuss his war experiences, that he has troubling intrusive thoughts as much as three times a day, nightmares six times a week, and flashbacks about twice a week. The veteran related that upon his return from military service, he was no longer interested in many of the things that had been important to him, including playing the trumpet and engaging in certain sports activities. He noted that he had great difficulty with others, and could not establish or even re-establish relationships. Further, he noted that job situations were especially difficult. The veteran further indicated during this examination that for a number of years after service, he would carry a knife around the house at two different times in the morning, and that sudden noises caused very marked startle reactions. The veteran also related odd visual and auditory hallucinations, including seeing snakes on the ground outside of his house every morning that disappear after a few minutes, seeing his dead mother, two brothers, and father. The veteran also indicated that people who did not know him were out to get him, and that there was a conspiracy to send him to jail. The examiner commented that the veteran was of average intelligence, and that he had a prior history of substance addiction (marijuana and alcohol) until 1993. As a result of this examination, the veteran was diagnosed with PTSD and schizophrenia, paranoid type, among other things, with unemployment, money and marital problems, and combat experiences listed as stressors. A GAF score of 45 was indicated. Analysis The veteran and his representative contend, in substance, that a disability evaluation higher than the 50 percent evaluation initially assigned following the grant of service connection for PTSD disability is warranted. At the outset, the Board notes that, recently, the Court observed that there is a distinction between a claim based on the veteran's dissatisfaction with the initial rating (a claim for an original rating) and a claim for an increased rating. It was also indicated that in the case of an initial rating, separate ratings can be assigned for separate periods of time based on the facts founds, a practice known as "staged rating." Fenderson, supra . By regulatory amendment, effective on November 7, 1996, substantive changes were made to the schedular criteria for evaluating psychiatric disorders, as defined in 38 C.F.R. §§ 4.125-4.132. See 61 Fed. Reg. 52695-52702 (1996). As noted above, where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas, supra. As reflected in the January 1999 rating decision, the RO has considered both the former and the revised applicable criteria; hence, there is no due process bar to the Board doing likewise, and applying the more favorable result. The Board points out that consideration will be given to the effective date of the revised regulation. In other words, for any date prior to effective November 7, 1996, the Board will not apply the revised psychiatric rating schedule to the claim, but from that date onward the Board will apply both the former and revised criteria. Prior to November 7, 1996, PTSD was evaluated using criteria from the general rating formula for psychoneurotic disorders. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). Under this formula, a 50 percent evaluation was appropriate where 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 were so reduced as to result in considerable industrial impairment. Assignment of a 70 percent rating was warranted for a severely impaired ability to establish and maintain effective or favorable relationships with people; the psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A 100 percent evaluation was contemplated where the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community; for 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; or for demonstrable inability to obtain or retain employment. Under the revised criteria, set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999), a 50 percent rating is appropriate where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. Assignment of a 70 percent evaluation is contemplated where 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 work-like setting); and inability to establish and maintain effective relationships. Assignment of a 100 percent evaluation for PTSD is contemplated where there is a showing of total occupational and social impairment, due to such symptoms as: gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives own occupation, or own name. That said, applying the evidence dated prior to November 7, 1996, to the old criteria, the Board finds that this evidence does not show that the veteran's PTSD produced more than a considerable (50 percent) degree of industrial impairment during that time period. While the relevant evidence indicates that during this time period, the veteran had difficulty sleeping, was irritable, depressed, angry, suspicious, and experienced nightmares, among other things, he was also articulate, alert, oriented, possessed fair judgment, was engaged in effective relationships, as demonstrated by references to his second marriage and subsequent girlfriend (fiancée), and was apparently able to engage in odd jobs, driving, shopping, and the like. Further, and as will be addressed below, the relevant objective evidence does not suggest that the veteran was severely impaired from obtaining employment solely due to his PTSD. The Board does point out that while in July 1993 the manifestations of the veteran's PTSD were said to extremely limit his employment options, the evidence reflects that the veteran was nevertheless employed at that time, and did not stop working until September 1993, just after the shooting incident. In considering the evidence dated subsequent to the change in regulation, the Board finds that an evaluation higher than 50 percent is not warranted under either the old or new rating criteria. Regarding the new criteria, the evidence does not demonstrate that the veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas 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; 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. While this evidence documents the veteran's complaints of hallucinations, nightmares, flashbacks, a depressed mood, and a flattened affect, he maintains an apparent healthy relationship with his girlfriend, and continues to be alert and helpful, oriented to time, place, and person, and is articulate. Furthermore, he demonstrates no memory problems. This evidence clearly demonstrates to the Board no more than a 50 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999) is warranted. As well, under the old criteria, again, the evidence shows that that the manifestations of the veteran's PTSD are no more than considerable with complaints as noted above. The evidence does not demonstrate that this disorder produces severe impairment in the ability to establish or maintain effective or wholesome relationships with people, or that the psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. As noted, the veteran does maintain at least some effective personal relationships (most notably with his girlfriend), and while it is arguable that the manifestations of the veteran's PTSD cause considerable industrial impairment, the evidence does not establish that such impairment is severe (it is noted that there is a physical component - specifically, the left foot injury - factoring into the veteran's alleged inability to maintain or obtain employment). As such, a 50 percent rating under 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996) is not warranted for the period after November 7, 1996. The Board does note that a GAF Score of 45 was indicated on VA examination in April 1998, and that, according to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), is indicative of severe symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). However, this is just one piece of information to be examined, and the Board is obligated to review all pertinent evidence and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Here, the evidence does not demonstrate that the veteran is currently suicidal, engages in severe obsessional rituals, or the like, nor has it been shown that PTSD alone causes serious impairment in social or occupational functioning. In conclusion, the Board finds that the evidence establishes that, since November 1990, the effective date of the grant of service connection for the veteran's PTSD, this disorder is shown to be no more than 50 percent disabling under either the former or revised applicable schedular criteria. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and an increased rating must be denied. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert, supra. It is pointed out that as this issue deals with the rating assigned following the original claim for service connection, consideration has been given to the question of whether "staged rating," as addressed by the Court in Fenderson, would be in order. However, as noted above, inasmuch as the 50 percent evaluation reflects the highest degree of impairment shown since the date of the grant of service, and that evaluation is effective since that time, there is no basis for staged rating in the present case. The Board finds, as did the RO, that the evidence of record does not present such an exceptional or unusual disability picture so as to render impractical the application of the regular rating schedule standards and to warrant assignment of an increased evaluation for either the service-connected PTSD on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (1999). As noted above, there is no showing that the veteran's PTSD has resulted in more than considerable (therefore, not marked) interference with employment, and there is no indication that this disorder has necessitated frequent periods of hospitalization. As noted above, while the veteran may in fact be unemployable, it is apparent that his nonservice connected left foot disability has significantly contributed to his functional limitations. Again, the veteran's apparent inability to maintain employment has been related to both psychiatric and physical impairment. In any event, there simply is no evidence that the veteran's PTSD alone (or together with his Raynaud's phenomenon of the hands and feet, for that matter) either renders him unemployable, or results in more than the considerable interference with employment contemplated by the assigned 50 percent evaluation assigned for this disorder. In the absence of evidence of such factors, the Board finds that criteria for submission for assignment of an extra- schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell; Floyd; Shipwash, supra. ORDER An increased evaluation for the service-connected Raynaud's phenomenon of the hands and feet is denied. As the initial 50 percent evaluation assigned for service- connected PTSD is proper, a higher evaluation is denied. LAWRENCE M. SULLIVAN Acting Member, Board of Veterans' Appeals