Citation Nr: 0944374 Decision Date: 11/20/09 Archive Date: 11/25/09 DOCKET NO. 08-25 744 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to a disability rating in excess of 70 percent for generalized anxiety disorder with depression. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Gina E. Fenice, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1944 to January 1946. This case comes before the Board of Veterans' Appeals (Board) on appeal of a March 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. Jurisdiction over the case was subsequently returned to the RO in Pittsburgh, Pennsylvania. In September 2009, the Veteran presented testimony at a Travel Board before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). FINDING OF FACT The Veteran's generalized anxiety disorder with depression is productive of social and occupational impairment that more nearly approximates total impairment than deficiencies in most areas. CONCLUSION OF LAW The criteria for a 100 percent disability rating for generalized anxiety disorder with depression have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION As a preliminary matter, the Board notes that the Veteran has been provided all required notice, to include notice pertaining to the effective-date element of her claim. In addition, the evidence of record is sufficient to establish her entitlement to the maximum schedular disability rating for her generalized anxiety disorder with depression. Therefore, no further development is required under 38 U.S.C.A. §§ 5103, 5103A (West 2002) or 38 C.F.R. § 3.159 (2008). Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2009). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2009). The Veteran's generalized anxiety disorder with depression is rated under 38 C.F.R. § 4.130, Diagnostic Code 9400, which provides that a 70 percent disability rating is warranted for generalized anxiety disorder when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted for generalized anxiety disorder with depression 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; and memory loss for names of close relatives, own occupation or own name. Where there is a question as to which of two evaluations shall 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. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Additionally, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2009). Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2009) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the Veteran's service-connected generalized anxiety disorder with depression. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. In this regard the Board notes that where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran was originally granted service connection for her anxiety disorder in a February 1946 rating decision. The disability was originally assigned a 30 percent disability rating, which was later reduced in 1948. However, the RO has since increased this rating in various rating decisions. Most recently, the disability rating was increased to 70 percent in a September 2005 rating decision. The Veteran filed the instant claim for an increased rating in August 2006. She appeals a March 2007 rating decision continuing the 70 percent rating. The Veteran contends that a disability rating higher than 70 percent is warranted for her generalized anxiety disorder with depression. In her September 2009 Board hearing, the Veteran indicated that she receives constant treatment for the disability and takes medication. After carefully reviewing the evidence of record, the Board concludes that the impairment from this disability more nearly approximates the total impairment required for a 100 percent disability rating than the deficiencies in most areas contemplated by a 70 percent disability rating. The Veteran was afforded a VA examination in December 2006 in response to her claim for an increased rating. At that time, the Veteran was reported to be unemployed, and living in a home with 3 or 4 of her grandchildren. It was noted that she did not have any friends or any social activities or hobbies and rarely left her room. Significant symptoms listed included nervousness, depression, decreased energy, isolative behavior, feelings of hopelessness and worthlessness. The Veteran also described having visions of an imaginary horse. Upon mental status examination, the Veteran's mood was dysthymic; but she was oriented to person, place, and time; and thought process was generally goal directed. Her insight was limited and judgment was fair. She did not endorse auditory or visual hallucinations, or suicidal or homicidal ideation. The examiner noted that her symptoms appeared to have worsened, as the Veteran now described anxiety that prevents her from performing tasks, and most notably, increased symptoms of depression in relation to her declining health. He found that the severity of her symptoms alone would likely render her unemployable. A Global Assessment of Functioning (GAF) score of 40 was assigned. VA outpatient treatment records from the period on appeal indicate that the Veteran has been seen on a continuous basis for her generalized anxiety disorder with depression. Symptoms noted included depressed mood, flat affect, and anxiety. The Board acknowledges that the medical evidence of record does not reflect that the Veteran experiences all of the symptoms associated with the maximum schedular rating. Specifically, the record does not show that she has persistent delusions or hallucinations, exhibits grossly inappropriate behavior, or is disoriented to time or place. However, the Court has held that the symptoms enumerated under the schedule for rating 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining that the Veteran's generalized anxiety disorder with depression warrants a 100 percent disability rating, the Board has considered the GAF score assigned for the Veteran. GAF scores are based on a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32. A GAF score of 31 to 40 signifies some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., where a depressed man avoids friends, neglects family, and is not able to work). The Board notes that while the Veteran was assigned a GAF score of 40 in December 2006, GAF scores do not correlate to any specific rating. The examiner specifically stated that the Veteran's generalized anxiety disorder with depression rendered her unemployable and the record indicates severe social impairment. These findings are consistent with the Board's decision to grant a 100 percent rating. In sum, the evidence of record contains a medical opinion evidencing that the Veteran is unemployable due to her generalized anxiety disorder with depression, and the record also reflects that the Veteran experiences severe social impairment with little interaction with others outside of her home. Thus, the evidence shows that the Veteran's generalized anxiety disorder with depression is productive of occupational and social impairment that more nearly approximates the total impairment contemplated by the criteria for a 100 percent disability rating than the lesser impairment contemplated by a 70 percent rating. Accordingly, the Veteran is entitled to a 100 percent schedular rating for her service-connected generalized anxiety disorder with depression. ORDER A 100 percent disability rating for generalized anxiety disorder with depression is granted, subject to the criteria applicable to the payment of monetary benefits. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs