Citation Nr: 1025262 Decision Date: 07/07/10 Archive Date: 07/19/10 DOCKET NO. 09-09 046 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to an initial rating in excess of 30 percent prior to September 25, 1998 and entitlement to an initial rating in excess of 50 percent from September 25, 1998 for generalized anxiety disorder. 3. Entitlement to a total disability evaluation based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Robert W. Legg, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. A. Wasik, Counsel INTRODUCTION The Veteran had active duty service from March 1964 to March 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to service connection for bilateral hearing loss was before the Board in September 2005 when it was remanded for additional evidentiary development. The issue of entitlement to service connection for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will inform the appellant if any further action is required on his part. FINDINGS OF FACT 1. Prior to September 25, 1998, the service-connected generalized anxiety disorder was manifested by symptomatology which was productive of, at most, definite social and industrial impairment. 2. As of September 25, 1998, the service-connected generalized anxiety disorder was manifested by symptomatology which is productive of total occupational impairment. 3. The Veteran submitted a claim of entitlement to TDIU in November 2008; a 100 percent disability evaluation will be in effect as a result of this decision as of September 25, 1998. CONCLUSIONS OF LAW 1. The rating criteria for assignment of an initial evaluation in excess of 30 percent prior to September 25, 1998 for the service-connected generalized anxiety disorder, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9400 (2009). 2. The criteria for assignment of a 100 percent disability evaluation as of September 25, 1998 for the service-connected generalized anxiety disorder, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9400 (2009). 3. The criteria for assignment of TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations set forth certain notice and assistance provisions. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). After reviewing the claims folder, the Board finds that the Veteran has been notified of the applicable laws and regulations which set forth the criteria for entitlement to an increased rating for the disability adjudicated by this decision. Specifically, the discussion in a January 2009 VCAA letter has informed the Veteran of the information and evidence necessary to warrant entitlement to an increased rating for his service-connected mental disorder. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements of 38 C.F.R. § 3.159(b)(1) have been met. The Board finds that all notice required by VCAA and implementing regulations was furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. In this case, the RO's decision came before complete notification of the Veteran's rights under the VCAA. It is arguable that the VCAA notice was not timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds, however, that any defect with respect to the timing of the VCAA notice in this case was harmless error for the reasons specified below. Subsequent to the rating decision on appeal, the RO did provide notice to the Veteran regarding what information and evidence was needed to substantiate the claim and the Veteran has had the chance to submit evidence in response to the VCAA letter. Under these circumstances, the Board finds that all notification and development action needed to render a fair decision on the claim decided herein has been accomplished and that adjudication of the claim, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). During the pendency of this appeal, on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. See Dingess/Hartman, supra. In the present appeal, the Veteran was provided with notice of what types of information and evidence were needed to substantiate his claim in the VCAA letter and he was also provided with notice of the types of evidence necessary to establish an effective date or a disability evaluation for the issue on appeal in the January 2009 VCAA letter. Additionally, the Board notes that this appeal arises from the grant of service connection for the generalized anxiety disorder where the Veteran has disagreed with the initial disability evaluation assigned. As a result of the grant of service connection and the assignment of a specific disability rating and effective date for the generalized anxiety disorder, section 5103(a) notice was no longer required. See Dingess at 490 (2006). All the VCAA requires is that the duty to notify is satisfied, and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). The Board also concludes VA's duty to assist has been satisfied. The Veteran's VA medical records are in the file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2009). The RO provided the Veteran appropriate VA examinations for the issue adjudicated by this decision. The Board finds that the VA opinions obtained in this case are more than adequate, as they are predicated on a full reading of the medical records in the Veteran's claims file. The reports of VA examinations conducted in February 2008 and June 2009 include sufficient reports of symptomatology to allow application of the ratings schedule. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions concerning the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4) (2009). The requirements of 38 C.F.R. § 3.159(c)(4) have been met. No additional pertinent evidence has been identified by the Veteran as relevant to the issue decided herein for which attempts to obtain the evidence have not been made. In February 2009, the Veteran's attorney reported that they did not have any further evidence to submit in support of the increased rating claim for the service-connected mental disorder. Under the circumstances of this particular case, no further action is necessary to assist the Veteran. Regarding the TDIU rating and compliance with the VCAA, the Board notes that the claim is denied herein as the Veteran does not meet the basic eligibility criteria; that is, he does not have a schedular rating that is less than total during the pertinent time period. Therefore, as no amount of assistance could affect the disposition of the claim, the Board finds that the matter of compliance with the VCAA is moot. Increased ratings criteria In April 1991, the Veteran submitted a claim of entitlement to service connection for post-traumatic stress disorder (PTSD). In August 2008, the RO granted service connection for generalized anxiety disorder and assigned a 30 percent evaluation effective from April 2, 1991 and a 50 percent evaluation effective from September 25, 1998. The Veteran has disagreed with the initial disability evaluations assigned by the RO. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations should be applied, the higher evaluation 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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. In deciding the veteran's claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007). In Fenderson, the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased evaluation claims. On November 7, 1996, new regulations became effective with respect to the criteria to be considered in mental disorder cases. 61 Fed. Reg. 52695-52702 (Oct. 8, 1996). Either the old or the new rating criteria may apply to the Veteran's case, whichever are more favorable to him, although the new criteria are only applicable to the period of time since their effective date. VAOPGCPREC 3-2000; 38 U.S.C.A. § 5110(g). Under the rating criteria previously in effect for evaluation of mental disorders, a 100 percent evaluation is warranted where the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. A 100 percent evaluation is also warranted if there are 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 aggravated energy resulting in profound retreat from mature behavior. The third, independent basis for a 100 percent evaluation is the veteran is demonstrably unable to obtain or retain employment. A 70 percent evaluation is warranted where the ability to establish and maintain effective or favorable relationships with people are severely impaired. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 50 percent evaluation is warranted where the ability to establish or maintain effective or favorable relationships with people are considerably impaired and by reason of the psychoneurotic symptoms the reliability, flexibility, and efficiency levels are so reduced as to result in a considerable industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (in effect prior to November 7, 1996). Under the current rating criteria for evaluation of mental disorders, a 100 percent evaluation 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 of names of close relatives, own occupation or own name. A 70 percent evaluation is assigned where the disorder is manifested by 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 that is 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 an inability to establish and maintain effective relationships. A 50 percent evaluation is warranted 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9400 (in effect since November 7, 2006). When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The diagnoses and classification of mental disorders must be in accordance with DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See 38 C.F.R. §§ 4.125 through 4.130. Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In assessing the evidence of record, the Board has reviewed the Veteran's Global Assessment of Functioning (GAF) scores. It is important to note that, as noted by the Court, a GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are 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). Id. GAF scores ranging between 31 and 40 are assigned when there is 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). Id. Factual Background In February 1991, the Veteran had an initial visit with VA health care providers with regard to his mental health. He reported he was heading for a nervous breakdown. He reported he was unable to sleep, he had nightmares, he was jumpy around noises, and he was irritable and listless. He indicated that he felt this way since his discharge from service. The symptomatology had increased in the last ten years. The Veteran denied suicidal or homicidal ideation. Another clinical record dated in February 1991 indicates that mental status examination showed the Veteran was coherent, relevant and spontaneous. There was no flight of ideas. Affect was appropriate. The Veteran denied suicidal thought, hallucinations and delusions. A third record dated in February 1991 indicates the Veteran reported he was in a seminary one year prior but left due to basic differences with the church. In February 1991, it was reported that the Veteran retired in 1989 from the state police after 21 years. The Veteran was self- referred due to insomnia, anxiety and depression related to his Vietnam experiences. He alleged that he retired on disability because of anxiety and angina. Mental status examination revealed the Veteran was oriented and presenting with PTSD symptoms which had increased since the Gulf War. He was guarded and anxious. He had retired from the state police earlier than he had planned due to stress. He was forced to retire one month prior to making sergeant due to angina problems. The Veteran was really depressed about this. The Veteran also spent one year in a seminary. He had gambling debts of $50,000 to $60,000. The axis I diagnosis was PTSD. In March 1991, it was noted the Veteran reported his early retirement from the State Police was a loss and a contributing factor to his stress and anxiety. Another record dated the same month reveals the Veteran reported that he described his retirement as a loss and spoke briefly of wanting to go back to work. However, he was feeling low energy and a lack of concentration which the examiner found was a description of PTSD/depression symptoms. The Veteran got into an argument with his father and was kicked out of his house. He was staying with a friend but hoped to stay with a brother. Another record dated in March 1991 shows the Veteran reported he was feeling somewhat less tense since he moved out of his parent's house and moved in with his brother and sister-in-law. He was sleeping somewhat better. The Veteran reported feeling overwhelmed and felt like doing something crazy like getting in a truck and driving nowhere in particular. Still another record dated the same month shows the Veteran reported he felt depressed on Monday as facing another week gets him down. His current living arrangement with his brother was going well. In April 1991, the Veteran reported he felt as if he was coming out of his depression somewhat and was able to read and concentrate better. The Veteran reported he was cleared to work but still lacked motivation. Another record dated the same month reveals the Veteran reported he was feeling better in terms of depressive symptoms. Sleeping was still troubled. He was still living with his brother and felt the next step was to get his own place. He wanted to get a job but had some fears about it. A third record dated in April 1991 shows the Veteran reported he was doing better. He reported he had a BA in criminal justice and a MA in education. He began a PhD program but did not complete it. He was in a Catholic seminary for six months but left in December 1989. In July 1991, the Veteran reported he had not spoken with his father since he had an argument four months prior. He was not going to his parent's house to mow the lawn anymore and was allowing others to pitch in. He reported he was happy and would be starting part time work for a police department in September teaching seminars on youth gangs and hate crimes. The Veteran was less anxious and his mood was stable. Another record dated the same month shows the Veteran was feeling some tension and having trouble falling asleep. His family had many medical problems recently. The Veteran was seriously considering returning to the Catholic seminary. In August 1991, the Veteran reported he was experiencing an exacerbation of his presenting symptoms from February 1991 i.e. depression, anxiety, increased smoking, eating, gambling, an inability to sleep and an increase in nightmares. The Veteran was unable to identify any one thing which was causing the exacerbation. Later the same month it was noted that the Veteran was unfocused and presented as pleasant, anxious and scattered. He reported he had recently gambled $2000.00 which he saw as a problem. The seminary was under the impression that the Veteran was going to return in September but the Veteran didn't think he wanted to go and didn't know what he wanted to do. In September 1991, the Veteran reported he went to the seminary but left shortly thereafter. He was positive he made the right choice as he felt many of the seminarians were confused about their sexuality. He felt he had permanently put to rest his attraction at becoming a priest. The Veteran wanted to perform service work on the outside. The Veteran reported he was gambling excessively. He appeared stable with an appropriate affect. A record dated later the same month indicates that the Veteran reported he felt emotions to the point of wanting to cry. In October 1991, the Veteran denied being depressed. He had not gambled in two weeks which was the longest time for his adult life. Later the same month, the Veteran reported he felt increased irritability lately. In November 1991, the Veteran moved into his own apartment. He was thinking about going back to work and was considering a truck driving job. Later the same month, it was reported that the Veteran presented as quite anxious and described feeling angry and sad but did not know why. The Veteran's day triggered PTSD symptoms. He was sleeping poorly and felt used and betrayed by a friend. The Veteran reported he could not afford to get angry but did not know why. He felt like it may be too overwhelming and he could become self-abusive such as returning to gambling or drinking. He denied suicidal intent. In December 1991, the Veteran was released from a hospital with a diagnosis of anxiety/panic attack with angina. The Veteran felt as if he was under stress as a result of looking for a job and from a women he was somewhat interested in. Later the same month, the Veteran reported he felt well after his discharge. He did not have any recent attacks. He submitted an application for a job with the Federal Aviation Administration (FAA) but was informed there was a hiring freeze until March 1992. The Veteran was talking more about wanting to/needing to find a job. Later the same month, the Veteran reported feeling more tense and anxious lately with nightmares and startle reaction. His mood appeared tense and anxious. The Veteran felt as if he wanted to find a job soon. In January 1992, it was noted that the Veteran wanted to find a job. He reported depression, loneliness, and frustration. He felt as if he was isolating himself but did not know how to socialize in a way he found enjoyable. The Veteran still had trouble concentrating. Several days later, it was noted that the Veteran was looking for a job but could not find one and was frustrated by the poor housing market. He was isolating more. He still had trouble falling asleep. His concentration was better and he was more focused. Later the same month, it was written that the Veteran was increasingly reluctant to socialize with people. A clinical record dated several days later indicates the Veteran was doing poorly. He was anxious, tense, had feelings of guilt regarding family issues, he was lonely and fearful. He was not sleeping well. He reported anger towards his father but denied hating or rage directed towards his father. He was fearful about the possibility of being hired in March for a federal job as he forgot how to act normally. He denied suicidal ideation. In February 1992, it was written that the Veteran presented as depressed and complaining of poor concentration and an inability to sleep. He had low self-esteem and felt guilty about family problems he had created after moving out of his parent's home to live on his own causing his other siblings to aid in the care of his parents. Prior to this, the Veteran had been shouldering total responsibility for his parent's care. He reported he had suicidal thoughts but no plans. He had been looking for a job but could not find one. He had been isolating at home. Another record from the same month shows the Veteran reported feeling lonely since living by himself in a one bedroom apartment. He denied suicidal thoughts or wishes for death. In March 1992, the Veteran discussed his inability to concentrate on anything, a lack of ability to sleep, guilty feelings, irritability and feelings of hopelessness towards the future. The clinician found that the Veteran met nine out of nine of the criteria for depression and anti-depressants were discussed. Another record shows the Veteran reported a marked change in his mood to more positive after starting anti-depressant medication. He was sleeping better and had less guilty feelings. He denied feeling depression or anxiety. He felt more energetic and better able to concentrate. He was very happy about feeling so psychologically well. Another record reveals he was feeling well assigning a score of six out of ten. He still felt anxious but his depression was better. The Veteran took an examination for a truck license and he thought he did well. He was also collecting information on an Emergency Medical Technician job in April. He felt happy and relieved to be out of his depression. Another record dated in March 1992 reveals the Veteran complained of vegetative signs and symptoms of depression including being depressed most of the day, marked diminished interest in almost all activities, significant weight gain, insomnia nearly every day, fatigue, poor concentration nearly every day, feelings of worthlessness and guilt and recurrent thoughts of death without a plan other than recently making his own funeral arrangements. It was noted by the clinician that a diagnosis of major depression seemed well established. Another March 1992 record shows the Veteran was being evaluated for his depression. He reported he was terminated in 1988 from the police due to stress related angina. After leaving the police, he spent two years in a seminary but left there disillusioned. The Veteran lived with his parents and was a very heavy gambler. The Veteran described feeling chronically depressed for most of his life. His current life was marked by anhedonia, increased anxiety and feeling of failure. He reported marked sleep disturbance characterized by racing thoughts. The Veteran alleged that he had no friends and his social network was made up of his immediate family. He denied suicidal plans but occasionally thought about it. There was no evidence of a thought disorder. The pertinent Axis I diagnosis was major depression and question PTSD. Still another record dated in March 1992 reveals that the Veteran discussed his inability to concentrate, a lack of ability to sleep, guilty feelings, irritability and feeling hopeless towards the future. In April 1992, the Veteran reported he stopped taking Prozac for a few days and he felt extremely depressed. Another record dated the same month reveals he was feeling a sense of panic and urgency that now that he was feeling better he must repair or make up for what he saw as his having been dysfunctional as a consequence of his chronic depression. Another record indicates the Veteran reported he was feeling less depressed but the symptoms had not remitted completely. He was sleeping okay. Concentration was improved but the Veteran was still not able to read books like as in the past. Another record demonstrated that the Veteran reported feeling much better that week. He denied feeling depressed. He had more energy and was better able to concentrate. Another record revealed the Veteran reported that he was still feeling anxious but he felt better after taking Prozac. He was sleeping better and denied suicidal thoughts. He felt lonely but found it difficult to "join." He would like to work but "can't." A VA clinical record dated in May 1992 indicates the Veteran reported that a great source of concern and stress was his inability to find a job. He reported there was nothing out there. Another record shows the Veteran reported he was feeling less depressed but was still unmotivated. Another VA clinical record dated the same month reveals the Veteran was a retired state police officer. It was noted that he was being seen for PTSD. He has been severely depressed but had no suicidal plans. He felt lonely and isolated now that he was disabled from working. Another record includes the annotation that the Veteran's depression was well controlled on Prozac but he still complained of poor concentration. On VA examination in May 1992, the Veteran reported that he withdrew from all social ties after his discharge from active duty. For all his working career, he choose to work nights specifically to get away from social interactions. He worked as a state policeman for 22 years at a desk or at the airport. He found himself so anxious and agitated that he turned to alcohol to numb out. He continued to limit his social commitments and worked as much as possible. He turned to gambling and is $100,000.00 in debt. As his cycle of poor social adjustment, increasing psychological agitation and indebtedness increased, he spiraled down from being able to live independently to living at his parent's house to living at his brother's house. At the time of the examination, he was living in a rooming house. The Veteran described symptoms of no energy. He felt sad, guilty, and without self-esteem. He had no interest in his surroundings and felt numbed out. He had no drive and no concentration. His anxiety, he felt, was extreme. He felt like he was going to explode and felt under a lot of time pressure. He continued to have vigilance and scanning, difficult with sleep and irritability. He continued with his social isolation. Mental status examination revealed that the Veteran was alert, oriented and cooperative. He was neatly dressed and coiffed. He acknowledged feelings of depression and anxiety but denied suicidality or homicidality. He showed no evidence of a thought disorder. His cognition appeared intact. He had a lack of insight into the nature of his very poor social interactions. He was only slightly better at understanding the intensity of his affect. The diagnosis was generalized anxiety disorder. In June 1992, the Veteran reported feeling distressed by his recent gambling binge. In July 1992, the Veteran twice reported becoming more social. One record indicated he was feeling better and his mood was stable. Another record dated the same month reveals the Veteran was spending time with his niece and nephew and also visiting a friend. He also had cancelled an appointment that month as a friend was visiting from out of town. In August 1992, the Veteran reported that he had felt he isolated too much. He was taking his niece and nephew to a science museum the next day. He felt better when he socialized with adults. Another record dated the same month reveals the Veteran reported he had been feeling increasingly depressed. He had feelings of guilt and low self-esteem. The Veteran was distressed because he had been eating more to try and comfort himself. He was still gambling. He denied suicidal intent. Another record shows he was taking his nephew and niece to a water park. The Veteran denied feeling depressed. Later the same month, the Veteran reported he felt tired and lethargic. He denied suicidal ideation and no vegetative signs or symptoms of depression except unmotivation to involve in activities. In September 1992, the Veteran reported he was doing okay. He still had trouble sleeping. Another record dated the same month reveals the Veteran reported he was not doing well. His gambling had increased the past two weeks. He continued to isolate in his apartment. His niece and nephew would be back in school next month and the Veteran would miss spending time with them. Another record reveals the Veteran reported he had been gambling excessively and was very depressed and isolated. Another record shows the Veteran reported a lack of concentration which he described as dissociative behavior that may have existed since childhood. In October 1992, the Veteran reported he was more anxious than usual. He had liquidated his possessions in his apartment, giving them to a needy neighbor. He planned to move in with his uncle. Another record dated the same month reveals the Veteran reported he had been more depressed and anxious that week and he had not gambled in five weeks. The author noted this was normal when withdrawing from addiction. Another record shows the Veteran reported he was still having nightmares about Vietnam as well as depression and guilt. A November 1992 VA clinical record shows the Veteran was happy with his living arrangements with his uncle. Another record dated the same month reveals the Veteran reported he felt well. Another record reveals he was less anxious. A VA clinical record dated in December 1992 shows the Veteran was found to have difficulty with intimate relationships. The Veteran was a retired police officer and had been in a seminary. The Veteran was retired due to angina problems. Another record dated the same month reveals the Veteran reported that the holidays were difficult for him. He thought living with a cousin was good for him. He was alert and oriented times three. Thoughts were logical and coherent. There was some blanking which the Veteran attributed to first meeting anxiety. He denied suicidal ideation and thoughts of death. Some pressured speech was noted. Another record reveals he denied depression. A private clinical record dated in December 1992 reveals the Veteran had angina pectoris and depression. It was noted that the Veteran continued to be under much stress with family related situations. He remained an anxious individual although he had improved somewhat. In January 1993, the Veteran reported feeling better about a friend. He felt decreased anxiety. He complained of sleep problems which were erratic, but he blamed this on medication. The Veteran was alert and oriented times three. Thought content was coherent. He was able to concentrate well. Mood and affect were appropriate. Later the same month, the Veteran denied any vegetative signs or symptoms of depression. He denied suicidal thoughts. He reported PTSD symptoms of nightmares, recurrent thoughts, guilt, anger and bitterness. In February 1993, the Veteran reported sleep disturbance. He woke up anxious as a result of not having a job and no funds. He denied nightmares. He was oriented times three and alert. His mood was irritable and affect was appropriate. A VA clinical record dated in April 1993 reveals the Veteran moved back with his father at his father's request. He reported feeling some guilt and shame over past experiences with his father. He reported less anxiety. The Veteran was alert and oriented times three. His mood was stable and his affect was appropriate. There was no suicidal or homicidal ideation. Another record dated the same month indicates that the Veteran reported sleep disturbance with early awakenings and middle insomnia. He had nightmares. He denied suicidal ideation. He was alert and oriented times three. Mood was stable and affect was restricted. He was well groomed and mourning the loss of his mother. The assessment was major depression in remission. In May 1993, the Veteran reported the death of a friend. This was the fourth loss for the Veteran in four months. He denied suicidal ideation or thoughts of his own death. The Veteran enjoyed his time with his nieces and nephews. The Veteran was alert and oriented times three. His mood was sad and affect appropriate. His thoughts were logical and coherent. There was no suicidal ideation. The diagnosis was major depression in remission. The Veteran testified in May 1993 that he was forced out the police department because of stress and angina. He reported a private physician linked the stress to the angina. A private clinical record dated in September 1993 reveals that the Veteran remains depressed. The Veteran was not working and remained extremely anxious. The clinician noted that he may need to see a psychiatrist if he did not come around. In April 1994, it was noted the Veteran had a history of exertional angina. In January 1995, a private physician wrote that the Veteran was under his care for angina pectoris. He was being treated for mild depression with Prozac. He had no active psychiatric complaints. The author could find no contraindication to the Veteran's obtaining a position in the Post Office. In February 1995, it was noted that the Veteran was to begin work at a Post Office. In February 1996, it was written that the Veteran felt well in general. He had occasional chest pain with emotional upset. He had resumed taking Prozac for depression. In September 1996, the Veteran denied depression or suicidal ideation. He had been on Xanax for years secondary to anxiety. A private clinical record from October 1996 includes the annotation that the Veteran was not depressed. A private psychiatric evaluation was conducted in October 1996. The Veteran's main complaint was depression for some months. He reported he would have a restless sleep and would awaken earlier in the morning than he would want to, feeling depressed and despondent. He described financial stress, health problems and self-esteem problems. He felt he did not concentrate as well as he might and he did not remember as well as he might. He lived with a brother. At the time of the evaluation, the Veteran was working as a driver for a firm delivering and picking up items. The Veteran acknowledged that many problems in the past were caused when he had problems with alcohol and gambling. Mental status examination revealed that the Veteran was casually dressed and clean shaven. He was oriented to person, time and place. Affect appeared appropriate and full range. The theme of the Veteran's conversation was that he needed help with his anxiety and depression. There were no delusions and no hallucinations. Insight and social judgment appeared good. The Axis I diagnosis was depression not otherwise specified and adjustment disorder with anxious mood. A private clinical record dated in December 1996 indicates the Veteran reported he was doing well on Prozac. A January 1997 VA clinical record reveals the Veteran's mood was stable and his sleep, appetite and energy were okay. Another record dated the same month reveals the Veteran related marked improvement with Zoloft. He felt that Prozac made him somewhat sedated. He reported a greater sense of energy. Sleep and energy were okay. A private clinical record dated in May 1997 shows the Veteran reported mood fluctuations and anxiety. A private clinical record dated in May 1998 reveals the Veteran reported some fluctuations in mood. A VA PTSD examination was conducted in September 1998. The Veteran reported that he retired from the police as a result of stress induced cardiac problems. The Veteran reported that he had not been able to work since his retirement from the police. It was clear to the examiner that the Veteran was experiencing significant depressive and anxiety symptomatology. The Veteran had sleep difficulty, low energy, poor self esteem, very considerable difficulty in concentration, and felt as if the future did not hold much for him. The Veteran became quite nervous and restless at times. He became preoccupied with his own problems and he experienced periods of irritability and anger. He led a fairly barren life. He never married, had virtually no friends and lived with his brother. The examiner opined that the Veteran's level of anxiety and depression were such that he was not employable at the time of the examination. The Axis I diagnoses were dysthymic disorder and generalized anxiety disorder. A GAF of 40 was assigned due to major impairments in multiple areas such as work, family relations, judgment and mood. A VA clinical record dated in November 2001 reveals the Veteran reported trigger reactions, wariness of others, nightmares, flashbacks, and difficulty concentrating. The Veteran lived with his sister. Another record dated the same month reveals the Veteran reported having strong periods of anxiety. A January 2002 VA clinical record reveals the Veteran reported he was a little uneasy during the holidays but got through it. He stated he didn't do much socially but did enjoy watching football. The Veteran was able to share positive experiences he had while working. Another record dated the same month shows the Veteran reported anxiety and having difficulty sleeping over the past week. The Veteran was verbal and spontaneous in discussion. He reported symptoms of nightmares, flashbacks, trigger reactions and wariness of others. A third record dated the same month indicates the Veteran reported he was feeling anxiety. He reported that his part time work seemed to be going alright and he felt better doing the work on a part time basis. A private clinical record dated in February 2002 indicates that the Veteran reported an increase in PTSD symptoms since 9/11. These included disturbed sleep with frequent nightmares, some social withdrawal and increased ruminations about his past traumatic events. He found counseling through VA was helpful. Mental status examination revealed that he was alert, pleasant and cooperative. Mood and affect did not appear depressed. He was mildly anxious discussing his symptoms. There was no suicidal ideation. A February 2002 VA clinical record indicates the Veteran reported he was sleeping better and was in a better mood. He had been taking a nephew to swimming class. He spoke positively about his niece and family. In March 2002, the Veteran reported uneasiness in relation to his sleep. The Veteran shared feelings of anger, sadness and isolation. In April 2002, the Veteran reported he was sleeping better. He reported positive relationships with his family. In June 2002, the Veteran reported symptoms of PTSD, flashbacks, wariness of others and isolation. Another record dated the same month reveals the Veteran had positive support from his family. His PTSD stressors were issues on a day to day basis. He reported staying away from crowds and social situations. The diagnosis was PTSD. In August 2002, the Veteran reported being a bit tired and anxious. Another record dated the same month reveals the Veteran reported he still was having difficulty sleeping. A VA clinical record dated in October 2002 reveals the Veteran reported anxiety and being upset the past week. Twice in December 2002, the Veteran reported anxiety related to the holidays. Another record dated the same month reveals the Veteran reported feelings related to his experiences in war time Vietnam and how it affected his day to day functioning. A third record dated the same month indicates that the Veteran reported having volunteered at a food pantry in his town on Christmas. A VA clinical record dated in January 2003 reveals that the Veteran had brought in a fellow Vietnam veteran to sign up and receive services at the clinic. In a January 2003 letter, a VA social worker reported the Veteran was receiving treatment for severe PTSD which greatly incapacitated his day to day functioning. The PTSD symptomatology caused flashbacks, trigger reaction, nightmares, wariness of others and ongoing isolation. In February 2003, the Veteran reported much anxiety related to beginning a part time job. The Veteran reported uneasiness and flashbacks related to his war time experiences. A VA clinical record dated in March 2003 reveals the Veteran reported being anxious on a day to day basis and needing to distance himself from others. He reported he had started helping his brother-in-law on a part time basis in the office and this had been extremely stressful for him. In April 2003, the Veteran reported anxiety related to war. He stated he had an exacerbation of symptoms of PTSD. Another record dated the same month shows the Veteran reported feeling anxiety and being upset related to his PTSD stressors. The Veteran shared strong feelings of being upset. In June 2003, the Veteran indicated that he had witnessed his nephew graduate from Annapolis. The Veteran was quite proud and feeling good about this accomplishment. In July 2003, the Veteran informed a clinician that he had much anxiety related to the Iraq war which he reported had triggered increased feelings of PTSD. He had moved from his sister's house to his brother's house. Another record from the same month reveals the Veteran reported he was getting acclimated to his new living situation at his brothers and things were getting better for him. He spoke about issues coping with anxiety. In August 2003, the Veteran informed a clinician that he was helping other Vietnam veterans. Another record from the same month reveals the Veteran spoke of anxiety and flashbacks. In September 2003, the Veteran spoke of anxiety, flashbacks and nightmares. Another record dated the same month shows the Veteran reported trouble sleeping the previous week. A VA clinical record dated in October 2003 shows that the Veteran spoke of anxiety and the difficulty he had doing part time work. Another record dated the same month indicates the Veteran shared concerns related to anxiety and how it had much impact on his day to day routine. The Veteran spoke of the difficulty being in crowds and needing space for himself. Twice in November 2003, the Veteran reported anxiety. A VA clinical record dated in May 2004 reveals the Veteran reported he was disabled due to a heart attack. There was no history of suicide attempts. He reported his first mental health care was in the mid 1980's just prior to his heart attack when he was experiencing panic attacks, anxiety and depression. The Veteran was never married and living with his brother and his family and indicated that he bounced around between the family. He retired at the age of 46 due to heart problems. He spent his time doing a lot of babysitting for his brother's kids. He alleged combat from Vietnam which had affected him tremendously with a lot of rage, a lot of sadness and a lot of loneliness. His sleep was reported to be lousy and concentration was poor. His mood was depressed most of the time or unhappy. There were no psychotic symptoms. The clinician observed apparent problems with memory as the Veteran's performance as a historian was poor considering his education. There was no sign of psychosis, no evidence of suicidal ideation. The assessment was combat related PTSD. A GAF of 40 was assigned. In August 2004, a social worker wrote that the Veteran had been receiving ongoing treatment for severe PTSD. The author wrote that the Veteran's traumatic experiences in Vietnam had resulted in confronting the debilitating symptoms of his condition on a daily basis. The Veteran was strongly incapacitated due to his PTSD condition. He had a marked and overwhelming inability to sustain and retain employment. The severity and magnitude of his PTSD disorder chronically impinged his day to day functioning. In April 2007, a private psychiatrist responded to questions presented by the Veteran's representative with regard to his psychiatric problem. The psychiatrist opined that the most appropriate diagnosis for the Veteran's mental disorder was generalized anxiety disorder which was directly attributable to the Veteran's military service. At the time of a February 2008 VA mental disorders examination, the Veteran denied having combat experience. It was noted that the Veteran was not married and had no children. He informed the examiner that he avoided family contacts. He reported no close intimate relationships and no friends. He informed the examiner that he had trouble trusting people and had problems making commitments to women. He denied having hobbies or leisure activities. There was no history of suicide attempts and no history of assaultiveness or violence. The Veteran reported that he was socially isolated. While he lived with other men, he tended to avoid contact with them. He reported no friendships or intimate contacts with women. He reported that he was still very anxious and depressed with little benefit from therapy for the 42 years he had been in treatment. The Veteran reported constant nervousness, reduced hours of sleep, sadness, anger, self- deprecation, he startled easily, social isolation, fatigue, and frustration. The Veteran's speech was spontaneous and his affect was nervous. Mood was anxious. He was oriented to person, time and place. There was an overabundance of ideas and circumstantiality of thought process as well as over inclusiveness. The Veteran was preoccupied with one or two topics and had ruminations. The Veteran had sleep impairment reporting only three or four hours of sleep per night. He sometimes had nightmares. There were no hallucinations and the Veteran did not exhibit inappropriate behavior. The Veteran did not interpret proverbs appropriately as he was confused at times. There was no obsessive or ritualistic behavior. The Veteran reported panic attacks noting he had some symptoms of panic such as sweating, dizziness if startled or if he berated himself at night he could become more anxious resulting in sweating and dizziness. There was no suicidal and homicidal ideation. Impulse control was fair without episodes of violence but with a history of gambling and alcohol abuse. The Veteran was able to maintain his hygiene. Recent and remote memory were normal and immediate memory was moderately impaired. It was noted that new information and new learning can be difficult to recollect. The Veteran was not employed and had retired in 1989 due to a medical (physical) problem. The examiner determined that the Veteran had pertinent Axis I diagnoses of generalized anxiety disorder and dysthymic disorder. It was noted that anxiety and dysthymic disorder are co-morbid and are often associated and interactive with each other. The examiner wrote that the Veteran had clearly been feeling anxious for several decades and used alcohol and perhaps gambling to avoid anxiety but, over time, he had also developed a depressive problem in the form of dysthymia. The examiner assigned a GAF of 50 commenting that the Veteran has clear serious impairment in social functioning and was retired for medical reasons but his anxiety might preclude his return to work even if he were eligible. With regard to whether Veteran had total occupational and social impairment due to mental disorder signs and symptoms, the examiner responded in the affirmative. He wrote that the Veteran's constant level of anxiety had only slightly been tempered by treatment over the last two decades. The Veteran had been out of work for nearly twenty years for medical reasons but evidence indicates that he had little emotional capacity to return to work except under the least stressful and part-time conditions. The most recent VA examination was conducted in June 2008. This examination was based on a review of the claims file only. The examiner summarized the evidence of record he found pertinent. The examiner concurred with the private psychiatrist's determination in April 2007 that the Veteran had anxiety reaction related to his military experiences. The examiner found that the Veteran had generalized anxiety disorder which was caused by military service. The examiner noted that the Veteran had an Axis II diagnosis of personality disorder which was described in the last VA examination which may also affect his functioning. The examiner noted that the Veteran's last GAF score was 50 with which he concurred. Analysis The Board finds that an initial rating in excess of 30 percent prior to September 25, 1998 is not warranted for the service- connected generalized anxiety disorder upon application of the rating criteria in effect up to November 7, 1996 nor is an increased rating in excess of 30 percent warranted for the service-connected generalized anxiety disorder when the disorder is evaluated under the prior and current rating criteria for evaluation of mental disorders from November 7, 1996 to September 24, 1998. The evidence set out above demonstrates that, prior to September 25, 1998, the Veteran advanced reports of problems with sleep, nightmares, irritability, anxiety, depression, low energy, lack of concentration, anger, startle reaction, loneliness, hopelessness, low self-esteem and pressured speech. The evidence of record indicates that these symptoms waxed and waned during the appeal period. The most consistently reported symptomatology was problems with sleep and anxiety. The Board finds this symptomatology is indicative of disturbances of motivation and mood. Furthermore, the pertinent evidence of record indicates that the Veteran experienced social impairment due to his mental disorder. However, while the Veteran has reported having no friends or few friends, he has consistently indicated that he was able to maintain relationships with at least some of his family during the entire appeal period. Significantly, the evidence regarding any occupational impairment which was associated with the service-connected generalized anxiety disorder does not support a 50 percent or higher evaluation under either the old or current rating criteria for evaluation of mental disorders. The evidence of record prior to September 25, 1998 indicates that the Veteran was having difficulty finding employment. The preponderance of this evidence does not support a finding that the inability to obtain employment was due to his service-connected mental disorder. In April 1991, the Veteran reported he was cleared to work but still lacked motivation and later the same month, he reported he wanted to obtain employment but had some fears about it. However, in July 1991, the Veteran informed a clinician that he had obtained part time work and was happy. The same month, the Veteran reported plans to re-enter a seminary. He briefly entered a seminary in September 1991 but left due to conflicts with his belief system and not due to any reports of problems with his mental disorder. In December 1991, the Veteran indicated that he was under stress looking for a job but there is no indication that the stress was productive of unemployment. Rather the evidence indicates the Veteran was actively seeking employment and was stressed he could not find any. The evidence does not indicate that the reason the Veteran could not find employment was his mental disorder. It appears from all the evidence that the stress was due to a limited job market not his mental disorder. For example, the same month, the Veteran reported he submitted an application for a job with the FAA but there was a hiring freeze until March 1992. There was no indication that the Veteran's mental disorder created any problems with regard to his attempting to obtain the FAA job. That month, the Veteran reported he wanted to obtain employment soon. In January 1992, the Veteran expressed being fearful over the possibility of being hired for the FAA job as he forgot how to act normally. This statement does not indicate that the service-connected mental disorder affected his ability to obtain employment as the Veteran had attempted to obtain the FAA job. He did not eventually get this job but there is no indication of any kind that the failure to obtain this employment was due to the mental disorder. In February 1992, the Veteran reported he was looking for a job but could not find one. In March 1992, the Veteran took an examination to obtain a truck driver's license and thought he did well on the examination. This evidence weighs against a finding that he had occupational impairment due to the mental disorder. In April 1992, the Veteran reported he would like to work but "can't." There is no indication in the record as to why the Veteran could not work at this time. Again it appears that the lack of employment was due to the job market and not the Veteran. In May 1992, the Veteran reported an inability to find a job but attributed this to a lack of job prospects. In February 1993, the Veteran reported anxiety as a result of not having a job. In January 1995, a private physician noted, in part, that the Veteran was being treated for mild depression and opined that there were no contraindications to the Veteran's obtaining employment at the Post Office and, in fact, in February 1995, the Veteran apparently started working at the Post Office. Subsequent to this time, he left this employment but the record is silent as to the reason. In October 1996, the Veteran reported employment as a driver for a delivery firm. He eventually left this job but the record is silent as to the reason for this. Based on the above, the Board finds the preponderance of the evidence is against finding that the Veteran experienced occupational impairment due to his mental disorder. As a result, the Board finds the evidence of record more nearly approximates a 30 percent evaluation prior to September 25, 1998, under either the old or current rating criteria. The Board finds that a rating in excess of 50 percent prior to September 25, 1998 is not warranted for the service-connected generalized anxiety disorder upon application of the rating criteria for evaluation of mental disorders which is currently in effect. With regard to the symptomatology specifically set forth for the 70 percent and 100 percent ratings, the Board finds the Veteran only reported problems with suicidal ideation and this symptomatology was only reported intermittently. At other times during the pertinent time period, the Veteran denied having suicidal ideation. Significantly, there is no indication in the claims file that the intermittently reported suicidal ideation had any effect on the Veteran's social or occupational functioning. The Veteran reported being depressed but there is no indication that this depression was "near-continuous." The Board finds that the service-connected mental disorder was not productive of an inability to establish and maintain effective relationships, nor occupational and social impairment with deficiencies in work, or family relations. With regard to the rating criteria previously in effect, for the reasons discussed above regarding the lack of evidence of industrial impairment, the Board finds a rating in excess of 30 percent is not warranted. The Board finds the pertinent evidence of record demonstrates that the Veteran has been able to consistently maintain relationships with family members and the preponderance of the evidence does not support a finding that the mental disorder was productive of any significant industrial impairment prior to September 25, 1998. The Board's inquiry is not necessarily strictly limited to the criteria found in the VA rating schedule. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) [the criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating]. However, the Board has not identified competent evidence of symptomatology associated with the Veteran's service-connected mental disorder which would enable it to conclude that the criteria for a higher rating have been approximated. The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis prior to September 25, 1998. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected generalized anxiety disorder is inadequate. A comparison between the level of severity and symptomatology of the Veteran's generalized anxiety disorder with the established criteria found in the rating schedule for evaluation of mental disorders shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for his service-connected generalized anxiety disorder. Additionally, there is not shown to be evidence of marked interference with employment due to the disability prior to September 25, 1998 for the reasons set out above. There is nothing in the record which suggests that the generalized anxiety disorder markedly impacted his ability to perform his job. In short, there is nothing in the record to indicate that the service-connected generalized anxiety disorder causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. The Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. The Board finds that a 100 percent evaluation is warranted for the service-connected generalized anxiety disorder as of September 25, 1998 based on total occupational impairment. The majority of the medical evidence dated during the pertinent time period which addresses the Veteran's industrial capacity indicates an inability to work due to symptomatology associated with the mental disorder. At the time of the September 1998 VA examination, the examiner opined that the Veteran was not employable due to his anxiety and depression. A GAF score of 40 was assigned at that time. In January 2003, the VA social worker wrote that the Veteran was greatly incapacitated in his day to day functioning. In May 2004, a clinician assigned a GAF score of 40. In August 2004, the social worker wrote that the Veteran was strongly incapacitated and had an overwhelming inability to sustain and retain employment. The examiner who conducted the February 2008 VA examination assigned a GAF score of 50 and opined that the Veteran had total occupational and social impairment due to mental disorder signs and symptoms. The examiner noted that the Veteran had been out of work for twenty years for medical reasons and that he had little emotional capacity to work except under the least stressful and part-time conditions. The examiner who conducted the most recent VA examination in June 2008 concurred in the GAF score of 50 assigned in February 2008. The other evidence of record dated subsequent to September 25, 1998 all indicates that the Veteran was either working part-time or not working at all. Furthermore, the clinicians noted that the Veteran expressed great anxiety even when working part time. The GAF scores assigned during the pertinent time period support a finding of industrial incapacity due to the service-connected mental disorder. GAF scores of 40 in September 1998, 40 in May 2004, 50 in February 2008 and 50 in June 2008 all are contemplative of, at best, being unable to keep a job (GAF of 50) or, at worst, unable to work (GAF of 40). This is indicative to the Board of complete industrial incapacity. The Board notes that the majority of the pertinent records dated subsequent to September 25, 1998 include diagnoses of PTSD. The examiner who conducted the February 2008 VA examination found that the correct diagnosis for the Veteran was generalized anxiety disorder and dysthymic disorder and noted that they are frequently co-morbid. This examiner found that the Veteran was unemployable due to anxiety. The Board notes that generalized anxiety disorder and PTSD are both included under the heading of anxiety disorders under 38 C.F.R. § 4.130. Furthermore, In Mittleider v. West, 11 Vet. App. 181 (1998), the United States Court of Appeals for Veterans Claims (Court) held that VA regulations require that, unless the symptoms and/or degree of impairment due to a service-connected psychiatric disability, here generalized anxiety disorder, can be distinguished from any other diagnosed psychiatric disorders, e.g., PTSD, VA must consider all psychiatric symptoms in the adjudication of the claim. Based on the above, the Board considers that all the reported mental disorders symptomatology is attributable to the service-connected generalized anxiety disorder. There is no medical evidence dated subsequent to September 25, 1998 which indicates that the Veteran is employable upon consideration of his mental disorder. Entitlement to a total rating based on individual unemployability. In November 2008, the Veteran submitted a claim of entitlement to TDIU. Generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent disability evaluation or, with less disability, if certain criteria are met. Id. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service- connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). When evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to TDIU will be considered "part and parcel" of the claim for benefits for the underlying disability. In such cases, a request for a TDIU is not a separate "claim" for benefits but, rather, is an attempt to obtain an appropriate disability rating, either as part of the initial adjudication of a claim or as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board finds that the evidence of record prior to September 25, 1998 did not raise the issue of TDIU. As set out above, the pertinent evidence of record dated during the appeal period indicates there were allegations of problems finding a job but this was not linked to the service- connected mental disorder. With regard to a TDIU claim as of September 25, 1998, the Board has determined that a 100 percent evaluation is warranted for the service-connected generalized anxiety disorder from this date. Additionally, there is no pertinent evidence of unemployability dated one year prior to this date. A May 1997 record only indicated mood fluxuations and anxiety without any indication that the Veteran was unemployable. Consequently, the Board finds that the claim for TDIU cannot be granted based on the award of the schedular 100 percent rating. 38 C.F.R. § 4.16(a) (TDIU may be assigned only where the schedular rating is less than total). ORDER Entitlement to an initial rating in excess of 30 percent prior to September 25, 1998 for generalized anxiety disorder is denied. Entitlement to a 100 percent schedular rating from September 25, 1998 for generalized anxiety disorder is granted subject to the laws and regulations governing monetary awards. Entitlement to TDIU is denied. REMAND In September 2005, the Board remanded the claim of entitlement to service connection for bilateral hearing loss, in part, to afford the Veteran a VA examination to determine the relationship, if any, between any current hearing disorder and the Veteran's active duty service. The Veteran has never been afforded the VA examination directed by the Board in its September 2005 remand. The Board notes the most recent evidence of record indicates that the Veteran's representative has reported that the Veteran was unable to appear for a VA examination due to experiencing residuals of a stroke. The representative specifically indicated that the Veteran had trouble with speech. The Board finds that, due to the nature of examinations for hearing loss, it is possible to evaluate the Veteran's current hearing acuity. It is possible for the Veteran to respond to cues from the examiner in a non-verbal manner. The Board finds it might also be possible for the examiner to determine if there is evidence sufficient to make a medical determination as to the etiology of the hearing loss based on a review of the claims file including review of prior statements submitted by the Veteran. In the case of Stegall v. West, 11 Vet. App. 268 (1998), the Court held that a remand by the Board imposes upon the Secretary of the VA a concomitant duty to ensure compliance with the terms of the remand. It was further held that where the remand orders of the Board are not complied with, the Board errs in failing to insure compliance. The Court also noted that its holdings in that case are precedent to be followed in all cases presently in remand status. Id. In light of the foregoing, this case must be remanded again for the actions set forth below. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide the names and addresses of all medical care providers who treated him for hearing loss since his discharge from active duty. After securing any necessary releases, obtain those records which have not already been associated with the claims file. 2. Contact the Veteran and his representative and determine if it is possible for the Veteran to appear for a VA audiological evaluation. If it is possible for the Veteran to appear, make arrangements with the appropriate VA medical facility for the Veteran to be afforded an audiometric examination by an audiologist to determine the relationship, if any, between any current hearing disorder, if found, and active service. The claims file must be made available to and pertinent documents therein reviewed by the examiner in connection with the examination. The examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination and reviewed. All appropriate testing, to include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test, should be conducted. The Board points out that the Veteran may be unable to participate verbally in the examination due to residuals of a stroke. See 38 C.F.R. § 4.85(c) (2009). The examiner should describe fully the functional effects caused by any bilateral hearing loss found on examination. Any further indicated special tests and studies should be conducted. The examiner must address the following medical issue: Is it at least as likely as not (50 percent or greater probability) that any hearing loss found on examination is related to service on any basis, including as secondary to the veteran's service-connected otitis externa with tinnitus? A complete rationale for any opinions expressed should be provided. If an opinion cannot be expressed without resort to speculation, the examiner should provide the rationale for why it is determined that speculation would be required. 3. After completion of the above, review the expanded record, and readjudicate the issue of entitlement to service connection for bilateral hearing loss. If the claim remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant and his representative have the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate (CONTINUED ON NEXT PAGE) action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs