Citation Nr: 0903154 Decision Date: 01/29/09 Archive Date: 02/09/09 DOCKET NO. 05-17 296 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent from October 1, 2003, to July 23, 2007, for service-connected generalized anxiety disorder. 2. Entitlement to an initial rating in excess of 70 percent from July 24, 2007, for service-connected generalized anxiety disorder. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD C. Chaplin, Counsel INTRODUCTION The veteran served on active duty from February 2003 to September 2003 and had prior active service of six months and reserve component service in the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) from an August 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico that granted service connection for generalized anxiety disorder rated as 30 percent effective from October 1, 2003. The Board remanded the issue in February 2007 for further development. A rating decision in July 2008 assigned a 50 percent rating effective from October 1, 2003, and a 70 percent evaluation effective from July 24, 2007. As those ratings are less than the maximum available rating, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. For the period from October 1, 2003, to July 23, 2007, the competent and probative evidence preponderates against a finding that the symptoms and manifestations of the veteran's service-connected psychiatric disorder result in occupational and social impairment in most areas or in total occupational and social impairment. 2. For the period from July 24, 2007, the competent and probative evidence preponderates against a finding that the symptoms and manifestations of the veteran's service- connected psychiatric disorder result in total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for generalized anxiety disorder have not been met for the period from October 1, 2003, to July 23, 2007. 38 U.S.C.A. §§ 1155, 5107(a) (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.130, Diagnostic Code (DC) 9400 (2008). 2. The criteria for an initial rating in excess of 70 percent disability rating for PTSD have not been met for the period from July 24, 2007. 38 U.S.C.A. §§ 1155, 5107(a) (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.130, Diagnostic Code (DC) 9400 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a complete or substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. This notice requires VA to indicate which portion of that information and evidence is to be provided by the claimant and which portion VA will attempt to obtain on the claimant's behalf. See 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. § 3.159 (2008). The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112 (2004); 73 Fed. Reg. 23,353 (Apr. 30, 2008). Here, the veteran is challenging the initial evaluation assigned following the grant of service connection for generalized anxiety disorder. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service- connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006)., Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155 (West 2002). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2008). In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. § 4.2 (2008). An evaluation of the level of disability present must also include consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2008). Also, where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2008). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When, after consideration of all the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. 38 C.F.R. §§ 3.102, 4.3 (2008). The veteran disagreed with the initial 30 percent rating assigned when service connection was granted for generalized anxiety disorder. During the appeal, the RO assigned staged ratings with a 50 percent rating assigned effective October 1, 2003, and a 70 percent rating assigned effective July 24, 2007. Fenderson v. West, 12 Vet. App. 119 (1999). The veteran's service-connected generalized anxiety disorder is rated using the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 (2008). A 50 percent disability evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9400 (2008). A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9400 (2008). A 100 percent rating is warranted for 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, DC 9400 (2008). The psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) scale reflects the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. GAF scores ranging from 71 to 80 reflect that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g. temporarily falling behind in school work). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. GAF scores in the range of 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). GAF scores in the range of 41 to 50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). GAF scores in the range of 31 to 40 contemplates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work.). Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association (4th ed. 1994) (DSM- IV); 38 C.F.R. §§ 4.125(a), 4.130 (2008); Carpenter v. Brown, 8 Vet. App. 240 (1995). After a review of the evidence, the Board finds that an initial rating in excess of 50 percent for the period from October 1, 2003, to July 23, 2007, and in excess of 70 percent from July 24, 2007, is not warranted. Service medical records show that shortly after the veteran had enlisted with the Army Reserve his unit was activated with future deployment to a combat situation. Within approximately two months after activation, based on manifestations of anxiety and an episode of chest pain, later thought to have been a panic attack, the veteran was evaluated and diagnosed with anxiety disorder, not otherwise specified, with a history of panic disorder. An evaluation in April 2003 described a panic disorder with depression. The veteran was found unfit for military duty and was attached to a Medical Holding Company to await separation from service which occurred in September 2003. When evaluated at a VA Psychiatric Intervention Center in October 2003 and November 2003, the veteran had good grooming and hygiene and was cooperative. His speech was spontaneous, coherent and fluent with adequate volume and production. His mood was well in October 2003 and anxious in November 2003. His affect was appropriate. His thought process was coherent, goal directed, relevant and he had no racing thoughts. He had no suicidal or homicidal ideation. He had no auditory or visual hallucinations and no illusions. He was alert and oriented times three. His recent and remote memory were intact and he had good concentration and attention. His insight and judgment were good. He was taking medication. The diagnoses were anxiety disorder not otherwise specified by history and panic attacks by history. A GAF score of 75 was assigned. At a psychiatric consultation at a Mental Hygiene Clinic in December 2003, the veteran was alert, coherent, and relevant but had difficulty answering questions related to his symptoms and the use of prescribed medications. He was not suicidal, homicidal, delusional, or hallucinating. He was well oriented. The assessment was history of generalized anxiety disorder that was stable with medications. A GAF of 40 was assigned. A January 2004 progress note indicates the veteran's history of anxiety disorder was stable with current management. A GAF score of 60 was assigned. At a VA mental disorders examination in June 2004, the veteran was appropriately dressed with adequate hygiene and was cooperative. He was alert and in contact with reality. His thought process was coherent and logical. There was no looseness of association and no evidence of disorganized speech. There was no evidence of delusions or hallucinations. He had no phobias, no obsessions, and no suicidal ideas. He reported occasional panic attacks. His mood was anxious. His affect was broad and appropriate. He was oriented in person, place, and time. His memory for recent, remote, and immediate events was intact. His abstraction capacity was normal, his judgment was good, and his insight was adequate. The examiner opined that the veteran's signs and symptoms were moderately interfering with his employment and social functioning. There was no impairment of thought process and communication and no evidence of inappropriate behavior. He was able to maintain basic activities of daily living. The diagnosis was generalized anxiety disorder with panic attacks and a GAF of 60 was assigned. A private psychiatric evaluation in September 2004 noted the veteran became anxious and nervous while trying to solve the problems inside of and outside of household. The private psychiatrist had seen the veteran on a monthly basis since May 2004. On examination, the veteran was noted as unclean. His voice was slow with logical and coherent articulation. His affect was sad. His attitude was cooperative. His motor behavior was slow. He was isolated or withdrawn. He denied auditory, visual, or tactile hallucinations. He denied suicidal or homicidal ideas. He had poor control impulses. He had poor interpersonal relationships. His mood was anxious and depressive. He was in contact with reality. His memory was adequate and concentration was poor. The private psychiatrist commented that the veteran's psychiatric symptoms had been accelerating with his physical illness and stress, which had disabled him to perform any kind of labor. The veteran described not visiting with family, friends, or neighbors. The conclusion was that the veteran was not mentally competent to carry out any kind of task and would not be able to achieve it. He needed to continue in psychotherapy for the remainder of his lifetime. On a checklist of occupational functioning, the veteran was evaluated as having no ability in order to operate in this area. He was judged not able to understand and remember complex instructions or instructions not complex at work. He was seriously limited in maintaining, understanding, and remembering simple instructions. He had no ability to maintain a good personal appearance or a stable emotional manner. He was seriously limited in demonstrating reality and relaxation. The diagnosis was severe major depression with psychotic features. At a VA mental disorders examination in January 2005, the VA examiner noted the September 2004 private psychiatric evaluation and report and commented that the psychiatrist described anxiety but diagnosed severe major depression with psychotic features. However, no psychotic features were described. January 2005 clinical findings were fair concentration, fair memory, clear and coherent speech, and fair insight and judgment. He was not suicidal or homicidal. No impairment of thought processes or communications were reported. No delusions or hallucinations were described. No inappropriate behavior was claimed. The veteran complained of inability to deal with people due to his irritability and aggressive reactions. He was oriented and no gross memory loss was reported. The veteran complained of having panic attacks and getting very anxious. He also suffered sleep impairment. The diagnosis was generalized anxiety disorder. A GAF of 60 was assigned. The VA examiner considered that, as on the June 2004 VA psychiatric evaluation, the current diagnosis was generalized anxiety disorder. The VA examiner considered the diagnosis of major depression with psychotic features given by a private psychiatrist was erroneous since his evaluation, findings, descriptions, and conclusion did not fulfill the diagnostic criteria for such a diagnosis. The veteran's private psychiatrist provided an evaluation report in May 2005. The veteran was casually groomed. His speech was slow and loud. He had no difficulty naming objects or repeating phrases. There were signs of severe depression. His thought content was depressed. His speech and thinking appeared slowed by depressed mood. He denied suicidal ideas or intentions. There were no signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations were intact, thinking was logical, and thought content was appropriate. His cognitive functioning was intact. His short term memory and long term memory were intact, as was his ability to abstract and do arithmetic calculations. He was fully oriented. His cognitive functioning appeared in the borderline range. His social judgment was poor. There were signs of anxiety and he was easily distracted. The diagnoses were recurrent major depressive disorder and post-traumatic stress disorder. The GAF score was 60/50. A March 2006 psychiatric evaluation by the veteran's private psychiatrist had findings of the veteran being unclean. He had a low voice with logical and coherent articulation. His facial expression was of sadness. His attitude was of cooperation. His motor behavior was slow. He was not isolated or withdrawn. He denied auditory, visual, or tactile hallucinations. He denied suicidal or homicidal ideas. He had poor control impulses and poor interpersonal relationship. His mood was anxiety and depressive. He had contact with reality, adequate memory, and poor concentration. The diagnoses were major severe depression with psychotic features and post traumatic stress disorder. The GAF score assigned was 65/60. A January 2007 psychiatric evaluation by the veteran's private psychiatrist noted that on examination, the veteran's voice was low. Articulation was clear, logical, and coherent. His facial expression was of sadness. He maintained eye contact and was cooperative. He did not present hallucinations and denied suicidal or homicidal ideas. He had a poor control of impulses and poor interpersonal relationship. He had no paranoia or delirium. His mood was depressive and anxious. He had appropriate contact with reality. His memory was adequate and concentration was poor. He had poor abstraction, judgment, and intro-vision. Some other symptoms noted on a checklist were not completely consistent with the findings reported on examination. The veteran's functional limitation was extreme in restriction of activities of daily living; maintaining social functioning; concentration, persistence or pace resulting in failure to complete tasks in timely manner; and episodes of deterioration or decompensation in work or work- like settings. The diagnoses were major severe depression with psychotic features and post traumatic stress disorder. The GAF assigned was 65/60. The private psychiatrist wrote that the veteran was not mentally competent to carry out any kind of task and would not be able to achieve it. He would need to continue in psychotherapy for the remainder of his lifetime. A Social Security Administration (SSA) decision in January 2007 found the veteran was disabled under appropriate sections of the Social Security Act from March 2003 through the date of the decision. The Administrative Law Judge considered a State agency medical opinion, the veteran's private treating psychiatrist's opinion, and the testimony of a medical expert at a hearing. Less weight was afforded the State agency medical opinion, and the Administrative Law Judge found that due to the veteran's psychiatric symptoms, he had marked restriction of activities of daily living, marked difficulties in maintaining social functioning, and marked difficulties in maintaining concentration, persistence, or pace. The favorable decision was based on the veteran's suffering from anxiety related disorders with recurrent and severe panic attacks that had caused significant limitations in his ability to perform basic work activities. Private treatment records from May 2004 to June 2007 show at the initial evaluation in May 2004, the veteran was oriented in time, space and person. The GAF assigned was "05 60". During that time period, the medical evidence shows no findings of the veteran having hallucinations or suicidal or homicidal ideas. He had serious depression, anxiety, impulse control and no panic. There was no change of diagnosis. For the last several months, his condition had improved. VA outpatient treatment records from October 2003 to September 2007 show that the veteran was seen on a periodic basis for follow-up of his anxiety disorder. GAF scores assigned during this period ranged from 40 to 75, with the majority being a score of 60. In October 2005, the veteran reported he had an imaginary friend who talked with him and the last time was three months earlier. However, he denied visual or auditory hallucinations at the time of the mental status examination. A GAF of 60 was assigned. In July 2007, the veteran was hospitalized for the first time for approximately a week and a half based on suicidal ideations. He reported a worsening of depressive symptoms since three weeks earlier. At the time of admission, his GAF score was 30. He had no homicidal ideas and no auditory or visual hallucinations were present. At discharge in early August 2007 he was coherent, relevant, and logical. He denied suicidal or homicidal ideas and reported no auditory or visual hallucinations. He was alert, awake, and oriented in regards to person, place, and time. His memory appeared grossly intact. His insight and judgment were fair. A GAF score of 45 was assigned. The diagnoses at discharge were severe recurrent major depressive disorder and generalized anxiety disorder by history. Following his hospital discharge, the veteran was followed at a private day hospital for approximately two and a half weeks in August 2007 for severe major recurrent depression with psychotic features. At discharge a GAF score of 50-55 was assigned. In mid-August 2007 the veteran was seen at a VA medical center for a refill of a prescription given to him at the day hospital. Upon interview, the veteran related still having some anxiety and insomnia but denied hallucinations, suicidal plan or ideas or homicidal ideas. He was calm and appropriately dressed and groomed. His speech was spontaneous, coherent, logical, and relevant. He felt better and his mood and affect were appropriate. He denied suicidal or homicidal thoughts, plans, or ideas. The diagnoses were severe recurrent major depressive disorder and generalized anxiety disorder by history. The GAF score assigned was 65. The examiner commented that the veteran had recently been discharged from psychiatry intensive care unit in early August 2007 and was in therapy at a day hospital. The examiner noted that the veteran was clinically improved as per the interview and external signs when compared with a previous evaluation done by the examiner. A VA outpatient treatment record in September 2007 indicates that the veteran reported that he became suicidal during the summer because he was not able to cope with all his medical ailments. He stated that he still felt a bit depressed but had been coping better. Clinical findings were that he was alert and coherent. He seemed calm but constricted in affective responses. No paranoid delusions were elicited and voices were denied. His sleep had improved. His mood was euthymic. He denied suicidal and aggressive thoughts, plans, and intent. The assessment was that the veteran seemed stable. After evaluating the evidence, the Board finds that for the period from October 1, 2003, to July 23, 2007, the veteran's disability picture due to his service-connected generalized anxiety disorder does not more nearly approximate the criteria required for a 70 percent rating under DC 9400. 38 C.F.R. § 4.7. The evidence discussed above does not demonstrate that the service-connected psychiatric disorder is by itself productive of occupational and social impairment with deficiencies in most areas. The private and VA medical records do not show the veteran demonstrated suicidal ideation or obsessional rituals interfering with activities. His speech was primarily described as logical, coherent articulation, fluent, with no evidence of disorganized speech. Illogical, obscure, or irrelevant speech was not noted. Spatial disorientation was not shown as the veteran was consistently fully oriented. Poor impulse control due to irritability was noted and in October 2005 when the veteran described an incident with policemen who intervened with his wife due to a transit violation. However, unprovoked irritability with periods of violence is not shown. The veteran described recurrent panic attacks and usually reported feeling sad and depressed. However, the evidence does not show it affected his ability to function independently, appropriately and effectively. There is some evidence that the veteran had difficulty in adapting to stressful circumstances. Although the private psychiatrist noted the veteran was unclean during at least two examinations, at another private evaluation, he was casually groomed and at VA examinations the veteran was noted to have adequate hygiene. To the extent more severe symptoms were described by the private psychiatrist, the assigned GAF scores do not reflect the presence of the same nor were severe symptoms found on VA examinations. GAF scores assigned at VA outpatient treatment from October 2003 to March 2006 ranged from 75 to 40 with the majority of the scores in the moderate range. GAF scores assigned by his private psychiatrist on examination were primarily in the range of moderate and mild symptoms. A GAF score assigned at VA examinations in June 2004 and January 2005 was 60 which is the high end of the range of moderate symptoms. Also the June 2004 VA examiner opined that the veteran's signs and symptoms moderately interfered with his employment and social functioning. While the veteran has indicated that he is frequently irritable and has difficulty with interpersonal relationships, it appears that despite those symptoms, he does not always interpersonally isolate himself. The inability to establish and maintain effective relationships was not shown. While he may have some difficulty forming effective relationships, an inability to do so is not demonstrated in the record. The veteran has been living with his wife and a child. The veteran also reported on examination in September 2004 that he did not drive and relatives or friends provided him with transportation. In sum, the Board finds that the veteran's symptoms do not more nearly approximate a 70 percent rating for the period from October 1, 2003, to July 23, 2007. Equivalent symptoms for an evaluation greater than 50 percent have not been shown. Furthermore, the Board finds that for the period from October 1, 2003, to July 23, 2007, and for the period from July 24, 2007, the veteran's disability picture due to his service- connected generalized anxiety disorder does not more nearly approximate the criteria required for a 100 percent rating. 38 C.F.R. § 4.7. The Board notes that the veteran is in receipt of disability benefits from SSA based on his psychiatric disorder. However, a decision granting the veteran SSA benefits is not controlling in a VA claim decision. Roberts v. Derwinski, 2 Vet. App. 387 (1992) (the fact that SSA has ruled that a veteran is disabled, under SSA law, does not establish, in and of itself, that the veteran is permanently and totally disabled for purposes according to the laws and regulations governing VA). The SSA decision indicated that the veteran's symptoms caused significant limitations in his ability to perform basic work activities but did not indicate that the veteran had total occupational and social impairment. The Board notes that the criteria used by the SSA in making such a determination differ from those shown in the regulations by which the Board is bound. Although the veteran's private psychiatrist wrote that the veteran's psychiatric symptoms disabled him to perform any kind of labor, that psychiatrist assigned a GAF score of 60/50 in May 2005, a GAF score of 65/60 in March 2006, and a GAF score of 65/60 in January 2007. Those scores reflect the highest score of serious symptoms, the highest score of moderate symptoms and a mid-range score of mild symptoms with most of the scores in the range of moderate and mild symptoms. Those symptoms do not more nearly approximate total occupational and social impairment. Furthermore, the Board finds that the VA examiners' findings are more persuasive because their findings are more appropriate to the findings of symptomatology by multiple examiners. The evidence does not show the veteran had persistent danger of hurting himself or others. Prior to his hospitalization in July 2007, the veteran consistently denied suicidal or homicidal ideation. At the time of admission in July 2007 for suicidal ideation, the veteran denied homicidal ideation. On discharge in August 2007 and when seen for follow-up the veteran denied suicidal or homicidal ideation. Although the veteran reported in October 2005 that he talked to an imaginary friend and the last time was three months earlier, the other evidence during the period shows that he consistently denied delusions or hallucinations. The Board finds that persistent delusions or hallucinations are not shown. Although the private medical evidence indicates some limitation of memory with regard to remembering and following instructions, clinical findings at private and VA examinations indicate the veteran's memory was intact and adequate. There is no evidence that he suffered memory loss for names of close relatives, own occupation or own name. Although there was some evidence that at two examinations in the period prior to his hospitalization, the veteran was described as unclean, other evidence shows his grooming was adequate. After his hospitalization, the evidence indicates the veteran was appropriately dressed and groomed. Although a private psychiatrist in January 2007 indicated the veteran had extreme functional limitation in restriction of activities of daily living, at that examination a GAF score of 65/60 was assigned which indicates moderate to mild symptoms. The evidence overall does not indicate intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. The veteran was consistently described as oriented. Disorientation to time or place is not shown. Symptoms of gross impairment in thought processes or communication are not shown. The evidence shows the veteran's speech was coherent, logical, and relevant. His thought process was coherent, goal directed, and relevant. There was no evidence of inappropriate behavior. Therefore, the Board finds that the evidence of record does not reflect psychiatric manifestations meeting or approximating the requirements for a 100 percent schedular rating. The evidence does not show total social and occupational impairment due to a service-connected psychiatric disorder. The veteran has not asserted, nor does the evidence suggest, that the regular schedular criteria are inadequate to evaluate his psychiatric impairment. There is no contention or indication that his anxiety disorder necessitates frequent hospitalization, or that the manifestations associated with this disability are unusual or exceptional. 38 C.F.R. § 3.321(b)(1). The Board finds that to the extent that his psychiatric disorder interferes with employment, that is contemplated in the 50 percent and 70 percent ratings already assigned. Thus, the Board finds that referral for consideration of an extraschedular rating is not appropriate. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In sum, the preponderance of the evidence is against an increased rating for any of the staged ratings presently assigned for the psychiatric disorder and for additional staged ratings. The manifestations exhibited by the veteran as presented in the evidence submitted in support of his request are appropriately evaluated with the current staged ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The preponderance of the evidence is against the assignment of an initial disability rating in excess of 50 percent for the period from October 1, 2003, to July 23, 2007; and in excess of 70 percent from July 24, 2007. As the preponderance of the evidence is against the claim for an increased rating, the claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 50 percent for the period from October 1, 2003, to July 23, 2007, is denied. Entitlement to an initial rating in excess of 70 percent for the period from July 24, 2007, is denied. ____________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs