Citation Nr: 1436790 Decision Date: 08/18/14 Archive Date: 08/27/14 DOCKET NO. 08-05 918 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an increased evaluation for major depressive disorder and generalized anxiety disorder, currently rated as 50 percent disabling. 2. Entitlement to service connection for a substance abuse disorder, to include: alcohol and cocaine abuse, secondary to a service-connected condition. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. M. Johnson, Associate Counsel INTRODUCTION This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Veteran had active service from August 1976 to September 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Offices (RO) in Milwaukee, Wisconsin in April 2007 and December 2008. The above-referenced December 2008 rating decision denied an increased rating for a depressive disorder and an anxiety disorder, which was rated as 30 percent disabling. In an August 2012 rating decision, the RO granted an increased rating for these conditions to 50 percent. Although a higher rating was granted, the issue remains in appellate status, as the maximum schedular rating has not been assigned from the date of claim nor has the appellant withdrawn his appeal. A.B. v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In June 2014, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. Additional evidence received at the hearing was accompanied by a waiver of RO consideration. See 38 C.F.R. § 20.1304 (c). The Veteran's entire claims file, to include the portions contained in the electronic "Virtual VA" system has been reviewed. The record before the Board can reasonably be construed to include a request for a TDIU; however, the RO has not determined whether the Veteran meets the criteria for a TDIU. As such, the claim is remanded for further development. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's depression and anxiety have been primarily manifested through symptoms that include: insomnia, flat-affect, anhedonia, panic attacks that occur more often than once per week, impairment of memory, and difficulty in establishing and maintaining effective relationships. 2. While the Veteran has reported recurrent audio and visual hallucinations and occasional suicidal ideation, the Veteran has not indicated suicidal intent during the appeal period and has stated that what he has endorsed as auditory hallucinations are his own inner voice. The Veteran's conditions has not manifested with internal preoccupation or overt psychosis. 3. The Veteran's symptoms have not produced occupational and social impairment with deficiencies in most areas. The Veteran maintains relationships with his mother, cousin, and his church, and has demonstrated linear thought process with appropriate thought content. 4. Throughout the appeal period, the Veteran has not been compliant with taking his medication for his depression and anxiety as prescribed. 5. The Veteran's alcohol and drug dependence result from his voluntary use of drugs and alcohol and are not secondary to any of his service-connected conditions. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for major depressive disorder and generalized anxiety disorder have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.130, Diagnostic Codes 9400, 9434 (2013). 2. The criteria for service connection for a substance abuse disorder, to include: alcohol and cocaine abuse, secondary to a service-connected condition have not been met. 38 U.S.C.A. §§ 105, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.301, 3.304, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims for an increased disability rating and service connection. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The RO provided the Veteran with a VCAA notice letter in December 2006 as to the service connection claim. In that letter, the RO addressed the information and evidence necessary to substantiate claims for service connection for alcohol abuse, addressed who was to provide the evidence, and informed the Veteran how VA assigns disability ratings and effective dates. Further, the April 2008 Statement of the Case sent to the Veteran addressed substance abuse beyond alcohol abuse and how such claims could be established. The Veteran received a letter in September 2008 regarding how to substantiate his claim for an increased rating for his service-connected depression and anxiety. It is pertinent to note that the Veteran has not pled prejudicial error with respect to the content or timing of VCAA notice, and has demonstrated that he is aware of how to substantiate his claims. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Court held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the 2014 Board hearing, the Veteran was assisted by a representative, and the undersigned Veterans Law Judge specifically asked questions that addressed the rating criteria for depression and anxiety and the criteria for obtaining service connection for a substance abuse disorder, as well as inquiring as to where the Veteran received treatment and suggesting updated treatment records would help the Veteran's claims. Moreover, neither the Veteran, nor his representative, has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2), and that any error in notice provided during the hearing constitutes harmless error. Regarding VA's duty to assist the Veteran in obtaining evidence needed to substantiate his claims, the Board finds that all necessary assistance has been provided in this case in regard to his claims. The Veteran's claim contains service treatment records, records of post-service treatment and examinations, hearing transcripts, and statements from the Veteran and his representative. The VA attempted to obtain records from the Social Security Administration (SSA), after it was indicated that the Veteran had applied for Social Security Disability Benefits, however, in May 2012 a formal finding of unavailability of SSA records was issued and was associated with the Veteran's claims file. The Veteran has had VA examinations performed by qualified medical professionals, who reviewed the Veteran's medical records. The examiners explained their findings and conclusions. The examinations and examination reports are adequate for the purpose of considering the appropriate ratings for the Veteran's disability. In that regard, the Board is satisfied that it has the most current assessment of the disability picture for depression and anxiety, and there is no need to obtain another VA examination addressing the severity of the Veteran's condition. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Indeed, as noted in detail below, the Veteran has provided updated treatment records regarding his condition since the last VA examination. Accordingly, there is no indication of any additional relevant evidence that has not been obtained, and there is no duty to provide another examination or a medical opinion in relation to his claim for an increased rating. See 38 C.F.R. §§ 3.326, 3.327 (2013). Entitlement to a Rating in Excess of 50 Percent for Depression and Anxiety The Veteran asserts that his PTSD warrants a rating higher than 50 percent for the period of appeal. During the Veteran's June 2014 video conference hearing, the Veteran and his representative specifically indicated that the Veteran's condition was more closely reflected by the 70 percent rating criteria for a mental disorder and that the Veteran's condition had worsened since 2012 or 2013. Unfortunately, the Board finds that the preponderance of the evidence is against the claim and the appeal must be denied. Disability ratings are determined by applying criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining a disability evaluation, VA has a duty to consider all possible regulations which may be potentially applicable based upon the assertions and issues raised in the record. Where 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. See 38 C.F.R. § 4.7. When, after careful consideration of all the obtainable information, a reasonable doubt arises regarding the degree of disability doubt will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. The Board must consider the application of "staged" ratings for different periods from the filing of the claim forward, if the evidence suggests that such a rating would be appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999); See Hart v. Mansfield, 21 Vet. App. 505 (2007). While the Veteran (and his representative) have specifically contended a worsening of his condition since 2012, the Board finds that the Veteran's symptoms have been consistent throughout the entire appeal period. Moreover, the Board notes that the Veteran also specifically asserts this himself in January 2012. The Board has reviewed all of the evidence in the Veteran's claims file with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Consequently, the following discussion will be limited to the evidence the Board finds to be relevant. In June 2008, the Veteran indicated that he was suffering from increased symptoms due to his service-connected depression and anxiety. The Veteran has indicated that he suffers from severe symptoms due to his mental condition and is unemployed and socially isolated as a result of his condition. During his video hearing the Veteran reported that while he has a girlfriend, it is not an effective relationship and that he doesn't really go out or socialize at all. He indicated that his condition keeps him from being able to adhere to an eight hour work schedule or working with a supervisor. The Veteran and his representative argue that the assessments provided by his examiners and physicians don't fully represent his level of incapacitation due to his service-connected mental conditions. Treatment records from the Milwaukee VAMC in January 2008 stated that the Veteran was had presented with complaints of memory problems, difficulty studying for his GED, and only sleeping one to two hours per night. He reported that his medication had not been effective; however, he admitted that he only was taking half of his prescribed medication and that he had periods of not taking it at all. The Veteran reported that he was frustrated with his inability to find a job and stated that he lives by himself and was not socializing in order to avoid temptation and drug use. The Veteran described episodes of "seeing the guy who hurt my eye," and having conversations with him. The physician noted that the Veteran seemed to have difficulty describing symptoms on his own, but could do so easily with multiple choices. The Veteran was noted to be alert, attentive, cooperative, and reasonable. His GAF was noted as 53-58 and his medications were increased. In March 2008, the Veteran reported that he was having increased difficulty despite his medication. The Veteran reported some benefits from the medication, but records indicated that he had not refilled his medication despite two months passing since his last appointment. He denied any side effects that were keeping him from taking the medication. The Veteran reported symptoms of anxiety, depression, and difficulty focusing. He reported recurrent thoughts about the events leading to his loss of vision and reported hallucinations regarding this event. The Veteran was reported to have a GAF score of 53-58 and was placed on new medications and his current medication was increased. The risks/benefits of not receiving pharmacological treatment were discussed with the Veteran. In October 2008, the Veteran was afforded a VA examination. The claims file was not reviewed. The Veteran reported increasing depression and difficulty focusing. He was dysphoric and described lashing out. He explained his daughter had to go back to her mother as he could not support her. He treated at VA. In November 2008, the Veteran underwent a VA examination and the examiner was able to review the claims file. It was noted that the Veteran had last worked in 2006 doing carpentry work for 2-3 months, but had lost his job due to VA appointments and head pain. The Veteran who has an 11th grade education was taking classes on refrigeration but had to discontinue these classes due to problems concentrating. He was reported to have contact with the younger two of his 4 children. The Veteran indicated that he had a casual girlfriend without a committed relationship. He reported that he has one good friend with whom he keeps contact from the center where he received treatment for alcohol abuse in 2006. He reported that he does not trust people and was upset at the time. The Veteran resided in his apartment by himself. He would usually go to bed around midnight and get up about 5 in the morning. He reported that his girlfriend would come over to make his meals and to do his shopping. He indicated that he took care of his own laundry and household chores. He reported watching minimal television during the day and attending school once per week. He also reported going to his cousin's barber shop and talking with other people there or visiting his family, but he did maintain that he spends a lot of time by himself in his apartment. At the time of the interview, the Veteran was casually dressed. He was noted to be pleasant and cooperative. His speech was spontaneous, logical and coherent. There was no current evidence of hallucinations or delusions. His sleep has been diminished to 4 to 5 hours per night and his weight and appetite were variable. He endorsed feelings of worthlessness and passing thoughts of suicide but without history or plan. Memory function was shown to be adequate and concentration was generally intact. Abstract reasoning was intact as evidenced by appropriate responses on tasks of similarities and parable interpretation. The Veteran was diagnosed with a depressive disorder and an anxiety disorder with a GAF score of 55. The examiner opined that the Veteran would be able to understand, remember and carry out simple instructions. His abilities and concentration were noted to be adequate for tasks at a simple to possibly moderately complex level. The examiner opined that responding appropriately to supervisors and coworkers was within his grasp. In November 2008, the Veteran was seen at the Milwaukee VAMC. The Veteran reported a depressed mood, but denied anhedonia and indicated that he enjoyed reading and playing billiards. He indicated that his depression had worsened recently and that he has been having flashbacks to his eye injury in service. He reported that he believes this injury was a turning point in his life that led him to depression, as well as alcohol and cocaine addictions. He endorsed nightmares regarding this injury and "always looking over [his] shoulder." He says while having a flashback, he sometimes sees the person who was engaging in "horseplay" that led to his injury. The Veteran denied any current suicidal ideation and denied homicidal intent. With regard to his current psychotropic medications, he reported that he has been compliant with them since his last visit but a review of his medications indicate that he picked up 30 days' worth of prescriptions in March, June, September, and October. When asked about this, he reported that he was taking enough medications and that he had been compliant in taking them. The Veteran reported that he does not feel that the medications have been effective and noted side effects of feeling dizzy and jittery. He reported that he received two disorderly conduct tickets approximately a month ago after he got into an argument over being asked to show identification at a billiard hall. He feels his group was unfairly singled out, which led to a verbal altercation. He denied any physical altercation. His insight and judgment were reported to be limited/poor. His GAF score was reported as 55. The Veteran underwent another evaluation at the Milwaukee VAMC in August 2009. He reported some difficulties with anger, especially because he had to repeat classes that he took last semester. He reported that feels his new medication has helped calm him a bit, but that he has missed about 5-7 doses per month since May. He noted having occasional "queasiness" about 8 hours after taking the medication. He still was struggling with poor appetite, insomnia, low energy, poor memory and concentration, flashbacks about his injury, and auditory hallucinations with comments about how he should have done more while he was in the service, occasional positive comments such as "things will get better." In October 2009, the Veteran reported that the medication changes were working. He said he felt less depressed and that he was sleeping a bit more but he hasn't noticed any improvement with his nightmares. He reported taking citalopram on only about half of the days, as he feels nauseated after taking it. The importance of taking the medication with food was reviewed. He stated that his classes were going ok, but he reported having some difficulty retaining the difficult material. He described his appetite and energy level as low. He described feeling "short tempered" lately, and reported that he feels like his children are "pulling away" from him. In February 2010, the Veteran presented for a medicine adjustment due to insomnia, nightmares, irritability, and anxiety in crowds. He reported that he "hears voices" which replay traumatic events in his head and that he feels like someone is watching him and might hurt him. In March 2010, the Veteran reestablished treatment with a therapist. He began receiving treatment once per month. In April, he reported increased anxiety and frustration related to his relationship with his son. He indicated that his son's mother and grandmother frequently interfere in their relationship. He has contacted the court for assistance and acknowledges he had done all he can at this time. He addressed his low motivation and accomplishing goals he has set. In June 2010, the Veteran reported that over the past couple months he has returned to drinking alcohol, roughly 4-6 can's/day of beer. He reported that psychotherapy was helping but that continues to have problems with memory. He says his goals are to be able to focus better and trust others more. His medications, including ramelteon and venlafaxine, were reviewed. He says he took the former medication nightly, but appreciated no benefit. He only took venlafaxine for 2 weeks, before switching to once daily at 50mg. He only filled this medication twice since February. The need for adherence to the prescription so that conclusions can be drawn regarding efficacy of the medication was reviewed. It was also discussed with him how alcohol use confounds both his symptoms and efficacy of medications. In August 2010, the Veteran did not present for his follow up psychiatric appointment. The Veteran was contacted by phone. He reported that he wasn't aware his follow up was today. He stated he has continued to drink alcohol "a lot" lately. He was reminded that if he is drinking alcohol, he is not allowing the medications a proper chance to be effective. Additionally, it was noted that he filled his psychotropics 7 weeks prior, but had not refilled his prescriptions since. In September 2010, the Veteran reported that he significantly reduced alcohol use to a "couple cans on the weekend" and that over the prior month he has been regular with taking his prescribed psychiatric medications, saying he missed only one day. He says cyproheptadine "helps me relax", quetiapine "helps me retain some information" and relax, and venlafaxine is "helping me somewhat" as far as mood. The Veteran did report that he still "hearing voices" such as "I should have done more." No internal preoccupation or overt psychosis was reported. In December 2010, the Veteran returned for a follow up visit. He reported that he feels his psychotropic medications are helpful (similar to last appointment), but notes residual depression, as well as ongoing memory problems (misplacing objects), and complains of difficulties socially (withdrawn, doesn't trust other people, says his children have kept their distance from him). Medication reconciliation indicated that the Veteran had been compliant with his medications. In May 2011, the Veteran reported pursuing his diploma and HS equivalency, and that he eventually hopes to work in heating/cooling. He reported ongoing memory concerns (describes mostly as forgetting where he put objects). He denied any relapse on cocaine, and says he has had 1 can of beer in the last 2 months. He reported improved compliance with his psychotropics and wasn't interested in any changes with his medication at this time. The Veteran described that what he has previously endorsed as auditory hallucinations are more of his own inner voice commenting on "things could be better if you had..." (remorse/guilt for not making different choices years ago). The physician noted that the Veteran was alert and oriented. His grooming and hygiene were appropriate. His eye contact was poor to fair and often diverted. He denied suicidal or homicidal ideation. He was future oriented and no internal preoccupation or overt psychosis was reported. In June 2011, the Veteran indicated that his son has been calling him. He and the mother have talked about resuming visiting but the Veteran was waiting. He stated that he will be awarded his diploma and discussed his thoughts that "doors were being closed on me' and recognized how his hard work and persistence paid off. He indicated that he was working on recovery but he continues to isolate. In July 2011, the Veteran was hospitalized due to atrial fibrillation. Upon admission, his urine drug screen came back positive for cocaine; although the patient denied using cocaine he said that he was at a party with his cousin where he may have inhaled cocaine. On day two of the admission, the patient complained of feeling tired and his speech was slurred. It was noted that upon admission his outpatient medications were continued, which included venlafaxine and quetiapine. The Veteran had been noncompliant with his medications at home and reported that he had stopped medications three weeks ago because he felt "drugged and too sluggish." He stated that he has been argumentative and irritable, and he doesn't want to be around people. He reported vague audio hallucinations, "someone cussing or telling me to hurt others, but I don't." He stated that he rarely leaves his house and sometimes doesn't even get out of bed. He has had some intermittent passive suicidal ideation but denies any presently. In September 2011, his physician noted that he has been off of venlafaxine for several months (30 day refill last obtained May 2011). His last refills of his other medications were in July. When asked, he says that maybe he forgot about venlafaxine, but says he is taking the other psychotropics as prescribed. He reported his mood is "down", that he doesn't feel motivated, and he is in bed a lot. He says he now has his HVAC diploma, but says his vocational rehab counselor told him he can't look for work currently due to physical health problems, particularly his atrial fibrillation. He noted ongoing 'inner voice', as he has described previously. He sometimes feels like somebody is watching him. In November 2011, the Veteran reported that venlafaxine has helped, "it mellows me out." He still reported room for further improvement in mood/anxiety, but declined dose increase at this time. He endorsed "thoughts of giving up" at times, but did not endorse any suicidal thoughts. He said he tends to sleep about 6 hours per day, but from about 5:30 or 6 am until noon. In January 2012, the Veteran reported his mood as 'in a slump". He identified that he has been isolating; but stated that he had been attending church and has developed positive relationship with his pastor. He reported that he had spoken with his son recently. In May 2012, the Veteran reported that his depression has worsened, as he isn't getting out of the house much. He reported poor energy. He was in intense outpatient addiction therapy (IOPAT) but says he had missed several appointments due to other commitments. He failed his high school equivalency exam. He denied any relapses on cocaine and only had one beer since February. He last filled his venlafaxine over four months ago. In July 2012, the Veteran underwent a VA examination regarding the severity of his current psychiatric condition. The examiner reviewed the claims file. The Veteran was diagnosed with depression, not otherwise specified and related anxiety and anti-social personality traits with a GAF score of 51. It was noted that his personality traits have a pervasive impact on his psychiatric symptoms and functioning that compounding his service-connected mental disorders. The examiner opined that it would be impossible to delineate which symptoms are related to which disorder without resorting to mere speculation. The examiner opined that the Veteran's conditions would cause occupational and social impairment with reduced reliability and productivity. The examiner reported that the Veteran had last treated with his psychiatrist in May 2012 at which time he reported worsening depression. He complained of nightmares and insomnia that were not responsive to his medication. It was noted that the Veteran had been off his venlafaxine for several months and that his depression had increased while off the medication. The examiner noted that previous therapy notes indicate that the Veteran's depression is "mild" with themes of relationship issues, (his son's mother denying visitation), physical health problems (he had hemorrhoid surgery in January 2012), anger management, and his efforts to remain sober. During the examination, the Veteran reported that he has been separated from his wife for decades, and has been in an "on and off relationship" for the past several years. He stated that his primary social contacts are this other woman and his mother, though he later mentioned contacts with people from church, his brother, and other acquaintances. The Veteran reported that he feels depressed most of the time. He indicated that his daily activities are limited and that he spends a lot of time in bed, sitting on his front porch, or watching TV. He reported that sometimes he is so depressed that he is "too weak to dress himself" and that he has to call his girlfriend to help him put on his pants about 3 days per week. He cooks simple meals for himself like TV dinners or hot dogs. The examiner reported that the Veteran completed the BDI-II (a self-report measure of depressive symptoms) and the BAI (a self-report measure of anxiety symptoms) . He failed to answer many items of the BDI-II but did endorse severe distress related to sadness, pessimism, and fatigue, as well as, moderate distress related to past failures, reduced appetite, and concentration problems. His score on the BAI was 42, indicated severe anxiety. He endorsed severe distress related to the following: wobbliness in legs, unable to relax, heart pounding or racing, nervous, fear of losing control, difficulty breathing, scared, and sweating. The examiner noted that the Veteran displayed symptoms of depressed mood, anxiety, suspiciousness, sleep impairment, flattened affect, difficulty in adapting to stressful circumstances, and neglect of personal appearance and hygiene. The examiner reported that when queried about specific symptoms, he had a positive response bias and some endorsed symptoms were out-of-proportion with his clinical presentation and the level of disability documented in his medical record (e.g., his claims that he frequently need help getting dressed and his auditory hallucinations). In September 2012, the Veteran reported taking venlafaxine as prescribed, and that this helped with his mood. He stated that over the past few months "finances" had not been going well, and he had mostly stayed at his apartment. He said he had missed some IOPAT meetings, which led him to be dismissed from vocational rehabilitation. He stated that his daughter was talking to him a bit more and did not describe any audio or visual hallucinations. In March 2013, the Veteran reported that "things are a little better" and that he was "trying not to be so stressed out." He discussed coping skills and he was able to identify multiple positive coping skills that work for him including educational TV, providing transportation to others, positive self talk, and comparing self to others. He shared that his mother was in auto accident and he had been providing her transportation to her appointments. He has also provided transportation to others. He was able to recognize that being busy and helping others has improved his mood. Relationships with his mother and children were reported as stable. In March 2013, the Veteran underwent another VA examination and the claims file was reviewed. The examiner opined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran reported that he mostly stay in his apartment watching, TV, trying to read books, or sleeping. He said that he has contact from a few friends or family members on the phone, and goes out to visit friends or family, to the store, or for doctors' visits. He reported that he has not worked for 10 years and his most recent job was through a temp agency. He said that his eye problems prevent people from hiring him, due to his eye wandering, poor peripheral vision, or appearing bloodshot. He reported that he has been trying to complete his GED and needs to pass one more test to do so. The examiner noted that the Veteran had been assigned a GAF of 50 during his most recent meeting in January 2012. The physician noted that his overall his functioning was similar to prior meetings. The Veteran described his depression as "horrible" and, that he does not do much, has few friends, he is angry all the time, he is uncomfortable in crowds, sleeps a lot, and he becomes angry quickly. He said he feels like this constantly and has felt this way since he started seeking help. He does not feel he gets much joy out of life but is looking forward to grandkids. He noted that he is unable to see some of his grandkids, however, due to issues with his kids. The veteran said he has crying spells about eight times per month when he is feeling lonely. He said he thinks about killing himself and vaguely described suicidal ideation. He said that in the evenings he will see shadows that appear to be objects in his apartment and he sees movement in the periphery of his vision. He talks out loud to himself and suggested he was responding to voices, but clarified on query that the voices were his thoughts. The examiner indicated that the Veteran had mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. He reported that there was no evidence of delusional thought content, and no evidence of a formal thought disorder. The examiner indicated that his documented GAF scores and most recent mental C&P remain in 'the 50-55 range, consistent with the current score, which was 55. The examiner opined that his depressive symptoms are imposing a moderate degree of impairment on his functioning, including his occupational functioning; however, the examiner opined that the Veteran's depression did not on their own preclude him from competitive employment and that his symptoms were similar to that documented in his July 2011 C&P exam. In September 2013, the Veteran reported that he had been depressed/anxious mood when he did not get his VA check and it was put in neighbor's mailbox. The Veteran was alert with good eye contact, linear thought process, and thought content appropriate to topic with no psychosis. In February 2014, the Veteran reported that he was frequently ruminating about what is not going well in his life particularly issues with his son. He also indicated that he has been experiencing panic attacks two to three times per week. The Veteran was seen by his psychiatrist in March 2014. It was noted that he last filled his medications in October 2013. He initially stated he had stayed on all his medications, but then he indicated that maybe he hadn't been taking them regularly. He says his son's brother was murdered, which has been tough to deal with. He reported not drinking alcohol these days and said he is going to church more. No use of cocaine was reported and used marijuana only "once" since last appointment. He did not endorse active suicidal ideation, but reports "I did have some thoughts of giving up on some things." He reported that talking with family members helps him. He reported occasionally seeing something "crawling out of the corner of his eye" and seeing "faces on the wall," which aren't there when he turns. The Veteran was seen again in July 2014 regarding his psychiatric condition. He indicated that he had been confined to his house for three weeks due to a cold, but that "he hopes to get outside more now." He indicated that he has continued with therapy and that a going to a skills group helps him cope with anxiety/depression. He indicated that he intends to attend a family reunion in Indiana later in the month. The Veteran reported that he was mistakenly taking 150mg of quetiapine all at once (and felt dizzy/lightheaded) and that he was off many of the psychotropics when he had his cold. He reported that he was compliant again now that he felt better. He was alert and oriented and grooming and hygiene were appropriate. Speech was normal rate and volume. Mood was grouchy and irritable. He denied suicidal or homicidal ideation. He reported unchanged audio/visual hallucinations of occasionally seeing something "crawling out of the corner of my eye" and also seeing "faces on the walls." He reported also hearing an external voice saying "things aren't going to work out, and that things aren't going to get better," which occurs two to three times per week. The Veteran's therapist and social worker submitted a letter regarding the Veteran's condition. She stated that the Veteran has been in treatment with me since July 2007 and that he frequently experiences intrusive thoughts of his experience in the military, which has an impact on his depression and anxiety levels. He has also expressed concern regarding his memory and that this has affected his ability to complete everyday tasks including class assignments. The Board must weigh the credibility of probative value of the competent evidence, accounting for evidence which it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the Veteran. Washington v. Nicholson, 19 Vet. App. 362, 366-67 (2005); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Equal weight will not be accorded to each piece of evidence contained in the record, as not every item of evidence has the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza v. Brown, 7 Vet. App. 498 (1995). When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign an evaluation 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. 38 C.F.R. § 4.126(a) (2013). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Under 38 C.F.R. § 4.130, Diagnostic Code 9411, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. A 50 percent rating is assigned 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9400; 9434. A 70 percent evaluation 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 situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, occupation, or own name. Id. A Global Assessment of Functioning (GAF) rating 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) (quoting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A Veteran's assigned GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard, at 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of a Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The global assessment of functioning (GAF) is a scale reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health-illness. Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). See Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). A GAF from 51 to 60 is defined as 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 co-workers). Scores ranging from 41 to 50 reflect 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). Scores of 31-40 reveals 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; child frequently beats up younger children, is defiant at home, and is failing at school). After reviewing all of the evidence of record, the Board finds that an evaluation in excess of 50 percent is not warranted at any time during the course of the appeal. The Veteran's symptoms have not been so frequent and disabling as to result in occupational and social impairment with deficiencies in most areas. During this period he never was described as having symptoms such as obsessional rituals, irrational speech, spatial disorientation, near continuous panic or depression, or neglect of personal appearance or hygiene. The record reflects the Veteran has retained some social relationships. He has been noted to have a girlfriend and some relationship with a couple of his children. During a November 2008 VA examination the Veteran also reported having a good friend and occasionally going to his cousin's barber shop or visiting his family. During a March 2014 treatment visit he indicated he was attending church. While relationships are strained and the Veteran spends a great deal of time by himself, the symptoms have not devolved to a point where he is manifestly unable to establish or maintain effective relationships. While the Board recognizes that the Veteran has indicated recurrent documented symptoms of great severity, particularly his audio/visual hallucinations and suicidal ideation, these symptoms regularly coincide with periods of noncompliance with the Veteran's prescribed psychological medications. In May 2011, when the Veteran was on his medications, he indicated that he was working towards his high school equivalency and reported that what he has previously endorsed as auditory hallucinations as his own inner voice recognizing mistakes that had occurred in his past. The record as a whole does not demonstrate that the Veteran's symptoms were so severe to cause deficiencies in most areas. In fact, in March 2013, when the Veteran was compliant with his medications he indicated that "things were a little better" and that he was "trying not to be so stressed out." He was able to identify multiple positive coping skills and reported tasks that he was able to complete, which included interaction with others. He also did not report any audio/visual hallucinations at that time. Similarly, while the Veteran has reported suicidal ideation, such thoughts have been intermittent and the record reflects times when the Veteran denied suicidal ideation and he consistently denied having a plan or intent. Similarly, while some memory impairment was noted, he was never noted to have memory loss so severe that he could not remember the names of close relatives, his occupation, or his own name. Additionally, after reviewing the evidence and interviewing and examining the Veteran, the VA examiner in July 2012 concluded the symptoms would result in reduced reliability and productivity and the March 2013 VA examiner concluded the symptoms resulted in occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. While the Veteran and his representative report that the Veteran's condition has significantly changed since he initially filed his claim for an increase, the Board notes that the Veteran's complaints of isolation, insomnia, and difficulty concentrating have remained relatively consistent during the periods that he has not been medicated. The Veteran stated this himself during his January 2012 C&P examination. The Veteran described his depression as "horrible" and, that he does not do much, has few friends, he is angry all the time, he is uncomfortable in crowds, sleeps a lot, and he becomes angry quickly. He said he feels like this constantly and has felt this way since he started seeking help. However, the evidence of record indicates that the Veteran has periods of relief from some of these symptoms when he is taking his medication as described. The Veteran's GAF scores also fail to support a higher evaluation. The Veteran's GAF scores have consistently been in the 50s with the lowest score of 50 being assigned during the March 2013 VA examination. He has never been assigned a score in the 40s which is indicative of some serious symptoms. Nor has he been assessed with scores in the 30s, which would be indicative of behavior considerably influenced by delusions or hallucinations, serious impairment in communication or judgment, or an inability to function in almost all areas. The Board also notes that many of the Veteran's reported symptoms are included among those specifically listed in the General Rating Formula for Mental Disorders, pursuant to which his 50 disability rating has been assigned. See 38 C.F.R. § 4.130. Importantly, the Board notes that symptoms noted in the rating schedule 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran's extent of occupational and social impairment. Accordingly, in this case, the Board finds that the existence and severity of the Veteran's psychiatric symptoms are adequately contemplated by the relevant rating criteria. As noted above, many of the symptoms are specifically listed in the General Rating Formula for Mental Disorders, and the others are common psychiatric symptoms that, while not specifically listed, are comparable indicators of the occupational and social impairment contemplated in the Rating Formula. The Board has considered the application of 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, and no referral is required. See Thun v. Shinseki, 573 F.3d 1366 (Fed. Cir. 2009). Here, the rating criteria reasonably describe the Veteran's disability and his symptomatology. As outlined above, the Veteran has reported nightmares, audio and visual hallucinations, social isolation, suicidal ideation, memory impairment and anger. Such symptoms are contemplated by the schedular criteria set forth in 38 C.F.R. § 4.130 , Diagnostic Code 9411. The regulations expressly consider each of these symptoms and further allow for other signs and symptoms of PTSD and depression which may result in occupational and social impairment. In other words, the currently assigned Diagnostic Code adequately contemplates the Veteran's symptoms. Therefore, the threshold factor for extraschedular consideration under step one of Thun has not been met. As the disability picture is contemplated by the rating schedule, the assigned schedular ratings are, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). Based on the foregoing, the Board finds that the rating currently assigned to the Veteran for depression and anxiety is appropriate throughout the appeal period and that the evidence of record preponderates against a finding in excess of a 50 percent rating. As such, the Veteran's claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 4.3. Service Connection for a Substance Abuse Disorder In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131. "Service connection" means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. See 38 C.F.R. §§ 3.303, 3.304. Direct Service Connection The Veteran has not specifically contended that his substance abuse disorder is directly due to his active service. However, the Board notes that the regulatory provisions of 38 C.F.R. § 3.301 address line of duty and misconduct determinations. Under 38 C.F.R. § 3.301(a), direct service connection may be granted only when a disability or cause of death was incurred or aggravated in line of duty, and not the result of the veteran's own willful misconduct or, for claims filed after October 31, 1990, the result of his or her abuse of alcohol or drugs. See also 38 C.F.R. § 3.1(m). The controlling precedential authority makes clear that direct service connection may not be granted for a disability that arises from a veteran's abuse of alcohol or drugs. Allen (William F.) v. Principi, 237, F.3d. 1368 (Fed. Cir. 2001). The Allen Court interpreted 38 U.S.C.A. § 1110 as precluding service connection for disability that results from primary alcohol abuse, which the Allen Court defined as "arising during service from voluntary and willful drinking to excess." Id. at 1376. In conjunction with 38 U.S.C.A. § 105, the Court concluded that Congress expressed a clear intent to preclude service connection for a primary alcohol abuse disability, and that primary abuse alcohol disability is included within section 105(a)'s and 1110's "express exclusion from compensation." Id. Accordingly, service connection on a direct basis is denied. See 38 C.F.R. § 3.1(m). Service Connection for a Substance Abuse Disability The Veteran has asserted that his alcohol and other substance abuse disability (or any related mood disorder) is secondary to his service-connected depression, anxiety, and his eye condition. The Veteran argues that his depressive mood will often cause him to want to drink or use other substances (such as cocaine or marijuana) to drown out his problems. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson, at 1313 (Fed. Cir. 2009). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). To prevail on the theory of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The Allen Court held that section 1110 allows for alcohol abuse disability under one circumstance, when such disability arises "secondarily from or as evidence of the increased severity of a non-willful misconduct, service-connected disorder." Id. at 1378. The Court reasoned that a secondary alcohol abuse disability "results from" a line of duty disease or disability rather than as a result of abuse of alcohol or drugs itself. Id. 1377-78. In other words, the Allen Court determined that the language of section 1110 reflected a Congressional intent that the cause of the alcohol-related disability determined whether the alcohol-related disability may be compensated under the statute, and that there were two mutually exclusive categories of causation: Either the alcohol-related disability is due to voluntary abuse of alcohol and therefore noncompensable or it is due to a service-connected condition in which case the alcohol abuse is involuntary and the disability is compensable. Id. at 1376-77. The Board notes that the Allen principles relating to alcohol abuse disabilities are equally applicable to drug abuse disabilities. While the Veteran contends that his substance abuse is secondary to a service-connected condition, particularly his mental disorders, the Board finds that this is not supported by the evidence of record. In March 2013, the Veteran underwent a VA examination regarding his service-connected mental conditions, including his substance abuse. The examiner noted that the Veteran's psychiatrist had diagnosed him with Depressive Disorder, NOS, Anxiety Disorder, NOS, alcohol dependence, cocaine abuse, and cannabis abuse. The examiner noted that at the time of the examination the Veteran reported drinking a beer or two approximately every two weeks. He indicated that he smokes marijuana twice a week due to his eye pain. He also stated that he has not used cocaine in the prior four years. However, it was noted that urine analysis from October 2012 was positive for cocaine. The examiner indicated that based upon the Veteran's report his alcohol and substance abuse problems were in remission and that it was less likely than not that the Veteran's substance abuse was caused or aggravated by his service-connected eye condition. The examiner stated that both the cocaine and alcohol abuse are in remission despite his eye problems continuing. While the examiner indicated the Veteran was using marijuana twice per week, this did not meet the DSM-IV criteria for substance abuse. In April 2013, the Veteran's file was reviewed by the March 2013 VA examiner. The examiner opined that it is less likely than not that the Veteran's alcohol, cocaine, and/or marijuana use or abuse is caused or aggravated by his service connected depressive disorder. Per the Veteran's report as noted in my examination of 03/25/13, his depressive symptoms are constant or nearly constant whereas his substance abuse is in remission (alcohol and cocaine) suggesting that alcohol and cocaine use are not in response to depressive symptoms. The Board finds the medical opinions discussed above to be highly probative evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295. The opinions are clear, direct, and supported by plausible rationales. Moreover, the Veteran has not submitted evidence that rebuts or challenges the examiner's conclusions. The examiner has opined that that alcohol and cocaine use are not in response to depressive symptoms (or his eye condition) as these conditions have persisted and the Veteran's conditions are said to be in remission. This opinion is further supported by the Veteran's statements in January 2008 that he was not socializing in order to avoid temptation and drug use, which indicates that least some component of Veteran's substance abuse was more likely related to social pressures. VA treatment records have been reviewed, but they fail to indicate that the Veteran's substance abuse was caused by his service connected psychiatric disability or his service-connected eye condition. As described, the medical evidence of record fails to associate the Veteran's alcohol/drug problems with his service connected psychiatric disability or his service-connected eye condition; and to the extent that the Veteran has alleged that such is the case, he lacks the medical training to be considered competent to provide such an opinion. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Therefore, because the Veteran's substance abuse disorder is not caused by or secondary to a service connected disability, it must be denied. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.301(d); Allen, at 237. ORDER Entitlement to an evaluation for major depressive disorder and generalized anxiety disorder in excess of 50 percent is denied. Entitlement to service connection for a substance abuse disorder, to include: alcohol and cocaine abuse, secondary to a service-connected depression, anxiety or eye disorder is denied. REMAND The Board notes that entitlement to a TDIU has not been developed or adjudicated by the AOJ. However, the U.S. Court of Appeals for Veterans Claims has held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). If the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted. Id. at 455. Throughout the appeal period, the Veteran has repeatedly contended that he is unable to work due to his service-connected conditions. During his March 2013 VA examination, the examiner indicated that the Veteran's service-connected psychiatric symptoms are imposing a moderate degree of impairment on his functioning, including his occupational functioning. While the examiner indicated that these symptoms on their on their own did not preclude him from competitive employment, the Board notes that no opinion has been provided regarding his ability to obtain and maintain employment based upon all of his service-connected conditions. The Veteran has therefore raised the issue of a total disability rating for compensation based on individual unemployability (TDIU). See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). Accordingly, the case is REMANDED for the following action: 1. The AOJ should send the Veteran a VCAA notice letter for the TDIU component of the increased evaluation claim. This letter should notify the Veteran and his representative of any information or lay or medical evidence not previously provided that is necessary to substantiate the TDIU claim. The notice should also indicate what information or evidence should be provided by the Veteran and what information or evidence VA will attempt to obtain on the Veteran's behalf. 2. After the above development has been completed, the AOJ should schedule the Veteran for a VA examination to ascertain if the aggregate effect of the Veteran's service-connected disabilities precludes him from securing and maintaining substantially gainful employment in light of his education and work history. A clear rationale for all opinions and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The RO/AMC shall then take such additional development action as it deems proper with respect to the claim. When the development requested has been completed, the case should again be reviewed on the basis of the additional evidence and readjudicated. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has 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 action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs