Citation Nr: 0004003 Decision Date: 02/15/00 Archive Date: 02/23/00 DOCKET NO. 92-09 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES Entitlement to service connection for atrial fibrillation, hypertension, and residuals of a cerebrovascular accident. Entitlement to a disability evaluation in excess of 50 percent for post-traumatic stress disorder. Entitlement to a disability evaluation in excess of 10 percent for a deviated nasal septum. Entitlement to an effective date earlier than May 11, 1994, for a grant of a 50 percent evaluation for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD William W. Berg, Counsel INTRODUCTION The veteran served on active duty in Marine Corps from June 1948 to June 1952 and is a combat veteran of the Korean War. When this matter was previously before the Board of Veterans' Appeals (Board) in January 1997, it was remanded to the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, for additional development. Following the requested development, the RO continued its denial of the claimed benefits. The matter is now before the Board for final appellate consideration. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained. 2. No competent evidence has been submitted relating the veteran's current atrial fibrillation, hypertension, and cerebrovascular accident residuals to service or to any incident in service. 3. It is not shown that the veteran's service-connected post-traumatic stress disorder caused or permanently worsened his atrial fibrillation, hypertension, and residuals of a cerebrovascular accident. 4. The service-connected post-traumatic stress disorder is manifested by anxiety with a related affect, flashbacks, recurrent nightmares, intrusive memories of combat, severe numbing of emotions, avoidant behavior, insomnia, startle response, impaired concentration, and depression; reality testing is sometimes impaired. 5. The veteran's current Global Assessment of Functioning Scale is 51. The service-connected post-traumatic stress disorder is productive of severe social and industrial impairment. 6. The veteran's reopened claim for an increased rating for post-traumatic stress disorder was received on May 11, 1994. 7. A rating decision dated in August 1996 assigned a 50 percent evaluation for post-traumatic stress disorder, effective from May 11, 1994. 8. It is not shown that the service-connected post-traumatic stress disorder was productive of considerable social and industrial impairment prior to May 11, 1994. 9. The service-connected deviated nasal septum does not, by itself, result in any unusual or exceptional disability factors such as to warrant extraschedular consideration. CONCLUSIONS OF LAW 1. The claim for service connection for atrial fibrillation, hypertension, and cerebrovascular accident residuals on a direct incurrence basis is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). 2. Atrial fibrillation, hypertension, and residuals of a cerebrovascular accident are not proximately due to or the result of service-connected disability. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). 3. The criteria for a 70 percent evaluation for post- traumatic stress disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Code 9411 (as in effect on and before November 7, 1996). 4. The criteria for a disability evaluation in excess of 10 percent for a deviated nasal septum have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.97, Diagnostic Code 6502 (effective prior to October 7, 1996). 5. The criteria for a disability evaluation in excess of 10 percent for a deviated nasal septum have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.97, Diagnostic Code 6502 (effective October 7, 1996). 6. The criteria for an effective date earlier than May 11, 1994, for a grant of a 50 percent evaluation for post- traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5107, 5110 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.400, 4.132, Diagnostic Code 9411 (effective prior to November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Service connection for atrial fibrillation, hypertension, and residuals of a cerebrovascular accident The service medical records are essentially negative for complaints or findings referable to atrial fibrillation, hypertension or cerebrovascular disease. The veteran's blood pressure when examined for service entrance in June 1948 was 134/74. On physical examination in October 1950, his blood pressure was 114/84 while recumbent, 114/88 while sitting, and 112/86 while standing. When he was examined for separation in June 1952, the veteran's recorded blood pressure was 110/74, and hypertension was not diagnosed. Chest X-rays during service showed no significant abnormality. Although a chest X-ray on June 20, 1952, was said to show "calcified hilar bilateral," it, too, was read as negative. On VA examination in June 1954, the veteran complained of difficulty breathing through his nose and of pain in his legs. His blood pressure was 128/70, and clinical examination was unremarkable for evidence of coronary artery or cerebrovascular disease. A chest X-ray was negative. Deviation of the nasal septum, with moderate obstruction, due to nasal fracture was diagnosed. Leg cramps of undetermined cause were diagnosed on a special peripheral vascular examination. When the veteran applied for VA hospital treatment in February 1955, his blood pressure was 130/88. The earliest indication of hypertension was on VA examination in April 1975, when chest X-rays were normal, except for slight elongation of the thoracic aorta. The record shows that the veteran was hospitalized by VA in June 1989, when an eight-year history of hypertension was elicited. The veteran reported that three months prior to admission, he "felt he was out of gas." Three weeks later, he developed sharp chest pain, which was non-radiating and lasted one minute, followed by short, more dull chest pain lasting 10 to 15 minutes. A week later, he developed a little shortness of breath, diaphoresis, and headaches behind the right eye. He felt like passing out. The diagnoses on discharge from the hospital in July 1989 were atrial fibrillation, hypertension, and cerebrovascular accident. In a letter to the veteran's treating physician dated in September 1989, Allan B. Minster, M.D., a private neurosurgeon, reported that the veteran had given a history of a "stroke" in June 1989, when he had experienced some numbness of the left side of his face, arm, trunk, and leg without specific weakness. Dr. Minster stated that apparently the veteran had sustained a right cerebral infarction three months previously with residual left hemianesthesia. In October 1989, Dr. Minster indicated that the veteran's sudden left hemiparesis was "presumably" from an embolism due to atrial fibrillation. In January 1990, a VA cardiologist reported that the veteran had severe uncontrolled hypertension, but the hypertension was not attributed to service. When seen at a VA outpatient clinic in June 1990, it was reported that the veteran had had atrial fibrillation in June 1987. When seen at an outpatient clinic in July 1990, the veteran complained of chest pains of three to four days' duration. He had hypertension and indicated that he had angina pectoris previously. When seen in the VA cardiology clinic later in July, the assessment was atypical chest pain without evidence of acute myocardial infarction. When seen in the VA gastrointestinal clinic on July 31, 1990, the assessment was atypical chest pain, possibly secondary to a "nutcracker" esophagus. When seen at the general medicine clinic in December 1990, a history of hypertension of 15 years' duration was noted. It was reported that the veteran had sustained a cerebrovascular accident a year and a half previously. VA chest X-rays during 1991 visualized atherosclerotic changes of the aorta and a slightly tortuous thoracic aorta. A VA record dated in May 1991 shows a history of chest pain since 1976 with normal angiography, cerebrovascular disease status post a cerebrovascular accident in June 1989 with hemiparesis, and a history of atrial fibrillation. Electrocardiograms beginning in 1991 showed premature atrial contractions (PAC's). The clinical records consistently show the onset of hypertension many years following service and the onset of atrial fibrillation in about 1987. The record unequivocally demonstrates that the veteran sustained a cerebrovascular accident in June 1989. Neither VA nor private physicians have attributed any of these disorders to service or to any incident in service. Although service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service, 38 U.S.C.A. §§ 1110, 1131, the threshold question is whether the veteran has submitted evidence of a well-grounded claim. A well-grounded service connection claim generally requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and medical evidence of a nexus between an inservice injury or disease and a current disability. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 524 U.S. 940 (1998); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). If a claim is not well grounded, the appeal must fail with respect to it, and there is no duty to assist the claimant further in the development of facts pertinent to the claim. Struck v. Brown, 9 Vet. App. 145, 156 (1996). Although the veteran has attributed his hypertension to combat in service, he is not medically competent to do so. Under the law, a lay person is not competent to render a diagnosis, or to offer a medical opinion attributing a disability to service, as this requires medical expertise. Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Thus, even if combat were conceded, a well-grounded service connection claim would not be shown in the absence of competent medical evidence linking the disability with service or an incident in service. See Kessel v. West, 13 Vet. App. 9 (1999) (en banc). In the absence of such competent evidence, the claim for service connection on a direct incurrence basis for atrial fibrillation, hypertension or residuals of a cerebrovascular accident is not well grounded and must be denied. See Edenfield v. Brown, 8 Vet. App. 384 (1995) (en banc). The veteran primarily contends that his service-connected post-traumatic stress disorder either caused or aggravated his atrial fibrillation, hypertension and cerebrovascular disease leading to his stroke. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). In his letter of September 1989, Dr. Minster noted the veteran's stroke the previous June and stated that the veteran had told him that he was known to have a combat- related stress disorder, "which certainly aggravates his present problem secondary to his stroke, the post-traumatic cervical radiculitis in his left arm, illness of his wife, etc." In its previous remand, the Board found Dr. Minster's letter to be significant because it was a letter to another physician reporting the findings of a neurological work-up that was conducted years prior to the holding in Allen. Although somewhat vague, the Board finds that Dr. Minster's statement is sufficient to well ground the veteran's claim for service connection for atrial fibrillation, hypertension, and cerebrovascular accident residuals secondary to service- connected post-traumatic stress disorder. See Jones v. Brown, 7 Vet. App. 134, 137 (1994) (secondary service connection claims must, like direct service connection claims, be well grounded). The Board remanded this claim in order to obtain medical clarification of, and etiologic opinion concerning the secondary service connection issue. The Board concludes, however, that service connection for the complex of disorders claimed is not warranted on a secondary basis. Although service connection is in effect for post- traumatic stress disorder, it is not shown that the post- traumatic stress disorder played any significant role in the development of the veteran's hypertension and cerebrovascular accident. Rather, the evidence tends to show that the cerebrovascular accident was caused by emboli as a consequence of the veteran's atrial fibrillation many years following service, the result of a pathological process completely unrelated to his service-connected psychiatric disorder. The Board notes that in September 1989, Dr. Minster stated that the veteran had been seen for neurosurgical evaluation at that time with a chief complaint of pain in his neck with "burning" pain radiating down his entire left arm rather diffusely to the hand. This started when he was sitting in a car that was stopped and struck from the rear by another vehicle in September 1989. The following month, Dr. Minster essentially attributed the veteran's sudden left hemiparesis to an embolism due to his atrial fibrillation. He did not attribute the underlying pathological process to service-connected disability. In a letter dated in June 1991, however, Ronald R. Klimaitis, M.D., the veteran's treating physician, stated that the veteran had been under his care for severe hypertension. Dr. Klimaitis stated that the veteran had suffered a "stroke" in June 1989 and that he continued to have difficulty controlling his hypertension. The least bit of emotional stress tended to drive his blood pressure to an unsafe range. He felt that the veteran was total and permanently disabled "in view of these facts." The VA cardiovascular examiner in May 1998 found that the veteran had high blood pressure with evidence of end organ damage such as left ventricular hypertrophy, cerebrovascular accident, and atrial fibrillation that are known complications of hypertensive cardiovascular disease. The physician reported that the veteran had a 22-pack-year smoking history and drank about a case of beer a day until his stroke in 1989. The physician opined, however, that the veteran's hypertension "could be related [to] or exacerbated by" post-traumatic stress disorder. However, in an addendum, the physician said that in most people, the cause of hypertension is unknown and that there is no way to know whether in a particular person hypertension is caused by post-traumatic stress disorder or to tell how much, if any, post-traumatic stress disorder contributes to chronic hypertension. The VA neurologic examiner in May 1998 stated following examination that the veteran's cerebrovascular accident was not caused by post-traumatic stress disorder but that post- traumatic stress disorder certainly could affect his recovery from his cerebrovascular accident psychologically. In an addendum, the physician stated that he had reviewed the claims file and noted that post-traumatic stress disorder and cerebrovascular accident are independent disease entities. The physician indicated that it was impossible to provide a qualitative response to the request for a complete rationale for the opinion regarding the etiologic relationship between the two. An etiologic relationship has not been established between the veteran's service-connected post-traumatic stress disorder on the one hand and his current complex of hypertensive cardiovascular and cerebrovascular disease on the other. The record contain suggestions, hints, intimations of a possible etiologic relationship between the disease entities, but a relationship that rises to more than the level of mere possibility is not shown. The recent opinion of the VA neurologic is little more than a conjecture, while the VA cardiovascular examiner flatly states that it is impossible to tell whether, or to what extent, hypertension in a particular individual is caused or aggravated by post-traumatic stress disorder. It bears emphasis that service connection may not be based on a resort to pure speculation or even remote possibility. See 38 C.F.R. § 3.102 (1999). See also Davis v. West, 13 Vet. App. 178, 185 (1999) (any medical nexus between the veteran's inservice radiation exposure and his fatal lung cancer years later was speculative at best, even where one physician opined that it was probable that the veteran's lung cancer was related to service radiation exposure); Bloom v. West, 12 Vet. App. 185, 186-87 (1999) (treating physician's opinion that veteran's time as a prisoner of war "could" have precipitated the initial development of his lung condition found too speculative to provide medical nexus evidence to well ground cause of death claim); Bostain v. West, 11 Vet. App. 124, 127-28 (1998) (private physician's opinion that veteran's preexisting service-related condition may have contributed to his ultimate demise too speculative, standing alone, to be deemed new and material evidence to reopen cause of death claim); Moffitt v. Brown, 10 Vet. App. 214, 228 (1997) (physician's opinion that "renal insufficiency may have been a contributing factor in [veteran's] overall medical condition" too speculative to constitute new and material evidence to reopen cause of death claim); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (on claim to reopen a service connection claim, statement from physician about possibility of link between chest trauma and restrictive lung disease was too general and inconclusive to constitute material evidence to reopen); Perman v. Brown, 5 Vet. App. 237, 241 (1993) (an examining physician's opinion to the effect that he cannot give a "yes" or "no" answer to the question of whether there is a causal relationship between emotional stress associated with service-connected post- traumatic stress disorder and the later development of hypertension is "non-evidence"); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that the veteran may have been having some symptoms of multiple sclerosis for many years prior to the date of diagnosis deemed speculative); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (evidence favorable to the veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by service radiation exposure is insufficient to establish service connection); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (service connection claim not well grounded where only evidence supporting the claim was a letter from a physician indicating that veteran's death "may or may not" have been averted if medical personnel could have effectively intubated the veteran; such evidence held to be speculative); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991) (medical treatise submitted by appellant that only raises the possibility that there may be some relationship between service-connected sickle cell anemia and the veteran's fatal coronary artery disease does not show a direct causal relationship between the two disorders such as to entitle the appellant to service connection for the cause of the veteran's death). Although the veteran's private physicians have suggested a possible link on the basis of aggravation between the hypertensive cardiovascular and cerebrovascular disease and the service-connected post-traumatic stress disorder, the opinions are not supported by clinical findings or diagnostic work-ups and are not shown to have been based on a review of service medical records or the claims file. See Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (rejecting medical opinion as "immaterial" where there was no indication that the physician reviewed claimant's service medical records or any other relevant documents which would have enabled him to form an opinion on service connection on an independent basis) (citing Reonal v. Brown, 5 Vet. App. 458, 460 (1993)); Swann v. Brown, 5 Vet. App. 229, 233 (1993) (without a review of the record, an opinion as to the etiology of the underlying condition can be no better than the facts alleged by the veteran). The opinion of a VA physician who has review the entire record is entitled to greater weight than the opinion of a physician who has not. See Wilson v. Derwinski, 2 Vet. App. 16, 20-21 (1991) (an opinion relating a current disability to service has more probative value when it takes into account the records of prior medical treatment so that the opinion is a fully informed one); Corry v. Derwinski, 3 Vet. App. 231, 234 (1992) (Board has a plausible basis to reject a physician's "conjecture" that a disability was acquired as a result of service where relevant treatment reports dating back a number of years were not mentioned by the physician rendering the opinion). Finally, the Board notes that while Dr. Klimaitis opined that stress tended to drive up the veteran's blood pressure to an unsafe range, that is not the same thing as finding that the service-connected post-traumatic stress disorder results in aggravation - a chronic worsening - of the nonservice- connected condition. Acute exacerbations without advancement of the underlying pathological disorder do not constitute aggravation under the law providing for compensation benefits. See Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Board therefore concludes that the preponderance of the evidence is against the claim for service connection for atrial fibrillation, hypertension and residuals of a cerebrovascular accident secondary to service-connected post- traumatic stress disorder. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Finally, the Board notes that the representative contended in a written argument dated in January 2000 that there was a failure of compliance by the RO with respect to the Board's request in the previous remand for medical opinions regarding the etiology of the cardiovascular and cerebrovascular disease, especially in relation to the service-connected psychiatric disability. The representative maintains that the cardiovascular and neurologic examiners failed to provide opinions that answered the question posed by the Board and that another remand is necessary in order to comply with the decision of the Court in Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board has reviewed the record and concludes that another remand would be an exercise in futility, exalting form over substance. The VA cardiovascular examiner ultimately concluded that it was not possible to answer the question posed by the Board, while the other opinions of record are grounded in speculation. They are not likely to improve with time. Although it is true that the reasons or bases requirement set forth in 38 U.S.C. § 7104(d)(1) is one requiring strict adherence, "strict adherence does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case. Such adherence would result in this Court's unnecessarily imposing additional burdens on the [Board] and [VA] with no benefit flowing to the veteran. This we cannot do. See 38 U.S.C. § 7261(b)." Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). B. Increased ratings for post-traumatic stress disorder and deviated nasal septum As a preliminary matter, the Board finds that the veteran's claims for increased ratings are plausible and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (a claim of entitlement to an increased evaluation for a service- connected disability generally is a well-grounded claim). The Board is satisfied that all relevant evidence has been obtained with respect to these claims and that no further assistance to the veteran is required in order to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41 and 4.42 (1999), and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the service-connected disabilities at issue on this appeal. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where the issue is entitlement to an increased rating following the filing of a reopened claim, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The evidence in closest proximity to the recent claim is the most probative in determining the current extent of impairment. Id. Under decision of the Court of Appeals for Veterans Claims in Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991), where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial process has been concluded, the version more favorable to the appellant applies unless Congress provided otherwise or permitted the Secretary of Veterans Affairs to do otherwise and the Secretary did so. Post-traumatic Stress Disorder The veteran's reopened claim for an increased rating for post-traumatic stress disorder was received on May 11, 1994, and was continuously prosecuted thereafter. The evaluation for post-traumatic stress disorder was eventually increased to 50 percent disabling, effective from May 11, 1994. In a written argument dated in September 1996, the veteran's representative contended that the veteran has the severe effects of post-traumatic stress disorder resulting directly from his combat service in Korea. The representative argued that the veteran was unable to obtain or retain employment and was in virtual isolation from everyone in his community. In essence, the representative argued for a 100 percent schedular evaluation for the service-connected psychiatric disability. Under the rating formula for neurotic disorders in effect prior to November 7, 1996, a 50 percent evaluation was warranted when the ability to establish or maintain effective or favorable relationships with people is considerably impaired, and by reason of the psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment; a 70 percent evaluation was for application when the ability to establish and maintain effective or favorable relationships with people is severely impaired, and when psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent schedular evaluation required that the attitudes of all contacts except the most intimate be so adversely affected as to result in virtual isolation in the community and that there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic and explosions of aggressive energy) associated with almost all daily activities resulting in a profound retreat from mature behavior; the individual must be demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132, Code 9411 (effective prior to November 7, 1996). A 50 percent evaluation under Diagnostic Code 9411, as amended, contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation under the newly revised criteria contemplates 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); and an inability to establish and maintain effective relationships. A 100 percent evaluation under the newly revised rating criteria requires 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. 38 C.F.R. § 4.130, Code 9411 (effective November 7, 1996). The Board notes that the RO has rated the service-connected post-traumatic stress disorder under both the new and old rating criteria for mental disorders and has provided those criteria in statements of the case issued to the veteran and his representative during the course of this appeal. Karnas. On VA psychiatric examination in May 1998, the veteran presented somewhat distressed. He reported that his spouse was quite ill and that he was her primary caregiver. Since his last rating examination in May 1996, the veteran said that he continued to have difficulty "getting off of the subject" of his Korean War experiences. He continued to attend a specialized group for Korean War veterans at a VA medical facility and reportedly received occasional psychotherapy at the facility. He also informally visited with other physicians and psychiatric technicians in the Stress unit whom he had come to know over the years since receiving treatment at that facility. The veteran reported that he still experienced difficulty with night sweats, as well as disturbed sleep from the nightmares he had had for many years. He continued to describe problems in relating to his family, particularly to his son and daughter, whom he tries to understand but has difficulty. He said that he had extreme difficulty relaxing and had ongoing problems with hypervigilance and exaggerated startle response. He said that he did not "want people around." He indicated that he had one friend from his unit with whom he felt comfortable talking. He described continuing problems with irritability and a short temper, which was primarily manifested in episodes of "road rage". He also said that he had problems with concentration. He described a foreshortened sense of the future manifested by a lack of attention to personal safety where provocation of others was concerned. He reported continuing problems with insomnia unrelated to any physical ailments. The examiner stated that the veteran was hospitalized in the Stress Disorders Treatment Unit in December 1996. The examiner stated that the veteran had subjective complaints of anxiety, hypervigilance, exaggerated startle response, intrusive memories of combat experiences, night sweats, nightmares of combat experiences, sleep disturbance, social avoidance, episodic lapses in concentration, and a foreshortened sense of the future. The examiner was of the opinion that these symptoms were attributable to post- traumatic stress disorder and that no other psychiatric diagnosis was other evident. A mental status examination revealed no evidence of major thought disorder, but the veteran was anxious, with appropriate and related affect. The veteran's affect rapidly shifted to tearfulness when describing episodes from his military history. But his eye contact was appropriate, his grooming and hygiene were within normal limits, and his speech was spontaneous and of normal rate and rhythm. He described no current lethal ideation. He said that he had not consumed alcohol in the previous two years. He had no cognitive or intellectual deficits, and his memory appeared to be intact. His insight and judgment were considered to be fair to good. He appeared fully capable of independently managing his funds without restriction. The diagnosis on Axis I was post-traumatic stress disorder, which was characterized as moderate to severe. The examiner remarked that moderate symptoms of illness persisted, with affective distress and interpersonal problems, resulting in impaired occupational and social functioning. When seen in the VA mental hygiene clinic in September 1998, however, his symptoms appear to have worsened. It was reported that the veteran had recurrent intrusive "horrifying" nightmares, flashbacks and memories of his combat experiences. He had had severe and disabling numbing of his emotions and avoided situations that reminded him of the event when his position was overrun by Chinese troops. He could not sleep and was startled by cars backfiring. He said that he heard voices continuously of his friend killed in action and frequently lost touch with reality as a result of his post-traumatic stress disorder. It was reported that he had tried to work over the previous 30 years but was unable to work because his impaired concentration and loss of touch with reality, and because of depression as a result of his post-traumatic stress disorder. The attending physician was of the opinion that for these reasons the veteran was completely unemployable and completely disabled from his post-traumatic stress disorder. His VA treating psychotherapist reported in a note dated in May 1999 that the veteran's symptomatology had been more or less consistent since 1994. Yet on VA examination in May 1998, the veteran's GAF scale was 51. The Global Assessment of Functioning is a scale reflecting the "'psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness.'" Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994) (DSM-IV)). A scale of 51 indicates symptoms resulting in moderate to serious impairment in social, occupational, or school functioning under DSM-IV. In fact, the findings seem somewhat in conflict. The record shows that the veteran has had anxiety with a related affect, flashbacks, recurrent nightmares, intrusive memories of combat, severe numbing of his emotions, avoidant behavior, insomnia, startle response, impaired concentration, depression, and the experience of hearing continuously the voice of his friend killed in action. He also reportedly lost touch with reality as a result of his post-traumatic stress disorder. It was reported that he had tried to work over the previous 30 years but was unable to work because his impaired concentration and loss of touch with reality, and because of depression as a result of his post-traumatic stress disorder. Yet a mental status examination in May 1998 revealed no evidence of major thought disorder, his eye contact was appropriate, his grooming and hygiene were within normal limits, and his speech was spontaneous and of normal rate and rhythm. He described no current lethal ideation. He said that he had not consumed alcohol in the previous two years. He had no cognitive or intellectual deficits, and his memory appeared to be intact. His insight and judgment were considered to be fair to good. He appeared fully capable of independently managing his funds without restriction. The diagnosis on Axis I was post-traumatic stress disorder, which was characterized as moderate to severe. The findings on VA examination in May 1998 do not differ markedly from those shown on VA examination in May 1996, when a significant history of disturbed sleep from dreams of war trauma was noted. The veteran then had a sense of feeling helpless and was reported to be "somewhat asocial" and avoided many things because even simple things could trigger combat memories. His occupational history was then described as "very spotty" and it was reported that the veteran was scarcely able to hold any long-term job. However, it was also reported that alcohol had been a considerable problem until about 1989. He reported that he often drank a case of beer a day after work and maybe some shots. Family relationships were very impaired apparently because, the veteran said, "People don't understand what I've been through and the effect it's had on me." The diagnosis was post-traumatic stress disorder. The examiner remarked that the disorder was pervasive and had had major adverse effects on the veteran's marriage, home life and employment. He had had a negligible social life because his combat experiences had been so intrusive. Other diagnoses were recurrent major depression, and alcohol abuse by history. In these circumstances, the Board will accord the veteran the benefit of the doubt and find that the evidence warrants a 70 percent evaluation for the service-connected post-traumatic stress disorder. 38 U.S.C.A. § 5107(b). It is clear from the evidence of record, however, that the veteran's numerous nonservice-connected organic disabilities, especially his cardiovascular and cerebrovascular disease, are seriously disabling, especially in an occupational sense, and that the veteran's overall social and occupational functioning is not totally impaired by the veteran's service- connected post-traumatic stress disorder. For example, in a statement dated in May 1990, Dr. Klimaitis, the veteran's private treating physician, said that he considered the veteran to be totally disabled due to uncontrolled hypertension. Dr. Klimaitis essentially reiterated this view in a letter dated in June 1991. It is significant that when the veteran was examined by VA in May 1991, his depression and memory loss were attributed to residuals of his cerebrovascular accident. On VA psychiatric examination in June 1994, post-traumatic stress disorder was diagnosed, but the veteran's memory deficits were attributed to residuals of his cerebrovascular accident. It was reported that he had not been able to work since he had his stroke. While the veteran undeniably has significant social and occupational impairment due solely to his symptoms of post- traumatic stress disorder, this is contemplated in the 70 percent evaluation now assigned. The rating schedule is designed to compensate for average impairments of earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (emphasis added). Moreover, prior to November 7, 1996, poor contact with other human beings was indicative of emotional illness, but social inadaptability was evaluated only as it affected industrial inadaptability. 38 C.F.R. § 4.129 (effective prior to November 7, 1996). The recent GAF scale of 51 assigned to the veteran's post- traumatic stress disorder is wholly inconsistent with any finding of total occupational and social impairment from the service-connected post-traumatic stress disorder such as to warrant a 100 percent schedular evaluation for that disability, whether evaluated under the new rating criteria or the old. Deviated Nasal Septum The record shows that the veteran sustained a fractured nose in service, which, while noted at separation, was not considered disabling. In April 1954, however, he was seen by a private physician, who found a marked deviation of his nasal septum to the right "so as to practically completely occlude" his right nares. The veteran said that he had no difficulty breathing through his nose until he fractured it in service. The physician stated that the obstruction was so great that it could only be corrected by a submucous resection. On VA examination in June 1954, the veteran complained of difficulty breathing through his nose, and an ear, nose and throat examination culminated in a diagnosis of deviation of the nasal septum (moderate obstruction) on the right, due to nasal fracture. By a rating decision dated in July 1954, service connection was established for deviation of the nasal septum due to fracture, and a noncompensable evaluation was assigned, effective from April 1954. (Service connection was also granted for leg cramps of undetermined cause, but a noncompensable evaluation was assigned.) The zero percent evaluation was thereafter continued under Diagnostic Code 6502 until a rating decision dated in August 1996, when the evaluation was increased to 10 percent, effective from January 17, 1990. During the course of this appeal, the criteria for rating a deviated nasal septum were changed by an amendment to the rating schedule that became effective October 7, 1996. 61 Fed. Reg. 46,720 (1996). Although under Karnas, the more favorable version of the rating criteria usually must be applied to a claim pending when the criteria changed, a 10 percent rating is the maximum schedular rating for the service-connected deviated nasal septum under both the old and the new rating criteria. An increased rating for this disability is only available if extraschedular consideration is appropriate under 38 C.F.R. § 3.321(b)(1). The provisions of the cited regulation were provided to the veteran and his representative in the statement of the case issued in August 1996. However, the record does not show that the deviated nasal septum results in such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. The record shows some difficulty with breathing through the nose as a result of the deviated septum, but there is no indication that the veteran has been frequently hospitalized for this problem or that it has, by itself, resulted in marked interference with employment. Rather, the record shows that the veteran has a number of other organic and nonorganic disorders that are more severe and are much more occupationally impairing, especially his hypertensive heart disease and cerebrovascular accident residuals, and his post- traumatic stress disorder. These disorders, and others, have been much the focus of treatment since he filed his claim in January 1990. Based on these considerations, the Board finds that the RO did not err in failing to refer this claim to the Director of the VA Compensation and Pension Service for an initial determination. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996). Although the veteran underwent a septoplasty at a VA medical center in April 1996 to correct his deviated nasal septum, there is no showing that the postoperative scar is infected or poorly nourished with repeated ulceration or that it is tender and painful on objective demonstration, nor is there any other showing of functional impairment as a result of the surgical scar. 38 C.F.R. §§ 4.118, diagnostic codes 7803, 7804, 7805 (1999). There is therefore no basis for a separate compensable evaluation for a postoperative scar arising from the service-connected condition under Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). C. Earlier effective date for a 50 percent evaluation for post-traumatic stress disorder The veteran's initial claim for service connection for post- traumatic stress disorder was received in January 1990. Following development of the claim, service connection was granted for post-traumatic stress disorder in a rating decision dated in October 1990. A 10 percent rating for post-traumatic stress disorder was assigned under Diagnostic Code 9411, effective from the date of receipt of the original claim on January 17, 1990. The veteran was informed of this determination in November 1990, but he did not disagree with the rating assigned. The October 1990 rating decision therefore became final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. §§ 3.104(a), 3.160(d), 20.302, 20.1103 (1999). On May 11, 1994, the veteran reopened his claim for an increased evaluation for post-traumatic stress disorder. A rating decision dated in October 1994 increased his evaluation to 30 percent, effective from May 11, 1994. In November 1994, the veteran disagreed with the evaluation assigned and with the effective date established for the 30 percent rating for post-traumatic stress disorder. In August 1996, following the submission of additional evidence and a hearing before a hearing officer at the RO, a 50 percent evaluation was established for post-traumatic stress disorder, effective with the date of receipt of the reopened claim. Under governing law, the effective date of an award of increased compensation is the earliest date as of which it is factually ascertainable that an increase in disability has occurred if the claim is received within a year from that date; otherwise, the effective date is the later of the date of increase in severity or the date of receipt of the claim. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125, 126-27 (1997). Accordingly, the issue is whether it was factually ascertainable between May 11, 1993, and May 11, 1994, the date of receipt of the reopened claim, that the post-traumatic stress disorder had undergone an increase in severity such as to warrant a 50 percent evaluation during that timeframe. With respect to this issue, only the rating criteria in effect prior to November 7, 1996, are applicable. See 38 U.S.C.A. § 5110(g). However, the evidence of record during the relevant timeframe does not show that the veteran manifested symptomatology that approximated or more nearly approximated the criteria necessary for a 50 percent evaluation under the rating criteria then in effect. 38 C.F.R. § 4.7. Although the veteran was seen at a VA mental hygiene clinic on numerous occasions during this period, his symptomatology was only moderate in degree. When seen in May 1993, he complained of nightmares three to four times a week. He said that he had interrupted sleep of about four hours a night. He had considerable flashbacks. However, his mood and energy level were good, and he did not feel helpless or worthless. He was not suicidal or homicidal, and he was able to participate in sporting activities such as swimming, golfing and fishing. He had good hygiene and maintained good eye contact with the therapist. There was no psychomotor agitation or retardation. Although his range of affect was slightly constricted, he was calm and cooperative. His speech was of normal volume and rhythm. Although he still had nightmares, he was not depressed. Treatment was with trazodone and Klonopin. He was to return to the clinic in six weeks. When seen in the VA mental hygiene clinic in June 1993, the veteran's mood was good, he was eating and sleeping well (six to seven hours a night) since the institution of Klonopin, although he had interrupted sleep. He attended therapy sessions, which were helpful. He went swimming three times a week and said that he enjoyed fishing and golfing. Although he felt helpless at times, he did not have feelings of hopelessness or worthlessness. He had no suicidal ideation. He had good hygiene and good grooming. He maintained good eye contact. His range of affect was normal with normal intensity. He was euthymic and normoactive. His speech was of normal rate and rhythm. The examiner felt that his post- traumatic stress disorder was under control and that there was no depression. A psychology service note in September 1993 reflects the veteran's problem with anger. When the veteran was seen in the Post-traumatic stress disorder Clinic in October 1993, he continued to have nightmares, disturbed sleep and intrusive recollections that did not seem to improve with trazodone. However, the veteran felt that overall, he was doing about the same as previously due primarily to clonazepam (Klonopin). A mental status examination was largely unremarkable, although the examiner commented that the veteran continued to have flashbacks and intrusive recollections and continued to feel a bit depressed and anxious all the time. The clonazepam was increased. A VA mental hygiene clinic note in November 1993 indicates that the veteran stated that he had memory problems from a stroke and since being treated with electroconvulsive therapy (ECT) for depression. The mental hygiene clinic progress notes thereafter reflect findings essentially consistent with those noted above. The veteran's symptomatology seemed to fluctuate only mildly, generally in response to variations in his medication regimen. The residual effects of his 1989 stroke were often noted, as were many nonservice-connected organic disabilities that afflicted the veteran. The veteran was oriented in all spheres when examined in the mental hygiene clinic in April 1994, although he had survivor guilt and increased arousal states. He reportedly saw shadows and heard voices even without the flashbacks. His mood was sad, and his affect was constricted. Klonopin was continued. The veteran had been treated with Zoloft, which was now increased. The assessment was post-traumatic stress disorder, and depression. It was not until a VA psychiatric examination in June 1994, however, that a significant increase in his symptomatology due to post-traumatic stress disorder is truly demonstrated. It was then that the veteran was not oriented in all spheres (he did not know the date), and he was described by the examiner only as "roughly oriented". He described his post-traumatic stress disorder symptoms in terms of his recollections of combat and began to get very upset and had difficulty controlling his emotions. He reported that his nightmares resulting from his combat experiences often caused him to wake up in a cold sweat. He also reported getting auditory; he would sit in a room and think that people were talking. He would open his eyes, and nobody was there. However, he had never had any ideas of reference. On mental status examination, his affect was of wide range but was colored by depression. His memory was quite affected, although this was felt to be a residual of his stroke. The pertinent diagnosis was post-traumatic stress disorder of moderate severity. The Board is of the opinion that an increase in symptomatology as a result of the service-connected psychiatric disorder simply is not shown prior to May 11, 1994, when his reopened claim for an increased rating was received. Indeed, even in June 1994, the psychiatric examiner felt that the post-traumatic stress disorder was productive of only moderate severity, a finding completely inconsistent with a 50 percent rating during relevant timeframe. It follows that an effective date earlier than May 11, 1994, for the assignment of a 50 percent evaluation for post-traumatic stress disorder must be denied. The evidence is not so evenly balanced as to raise doubt concerning any material issue. 38 U.S.C.A. § 5107(b). ORDER Service connection for atrial fibrillation, hypertension, and residuals of a cerebrovascular accident is denied. A 70 percent evaluation for post-traumatic stress disorder is granted, subject to controlling regulations governing the payment of monetary benefits. An increased evaluation for deviated nasal septum is denied. An effective date earlier than May 11, 1994, for the grant of a 50 percent evaluation for post-traumatic stress disorder is denied. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals