Citation Nr: 1001985 Decision Date: 01/12/10 Archive Date: 01/22/10 DOCKET NO. 08-37 456 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for anxiety disorder with alcohol abuse. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD G. Jackson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1950 to June 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by the RO. The Veteran and his wife testified before the undersigned Veterans Law Judge (VLJ) in a video-conference hearing in November 2009. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Anxiety disorder with alcohol abuse is shown to include no more than mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. CONCLUSION OF LAW The criteria for the assignment of an evaluation in excess of 10 percent for the service-connected anxiety disorder with alcohol abuse have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130 Diagnostic Code 9413 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled by information provided to the Veteran in correspondence from the RO dated in February 2006 and May 2008. Those letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claim and identified the Veteran's duties in obtaining information and evidence to substantiate his claim. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006). Effective May 30, 2008, 38 CFR 3.159 was revised to clarify that no duty to provide section 5103(a) notice arises "[u]pon receipt of a Notice of Disagreement" or when "as a matter of law, entitlement to the benefit claimed cannot be established."38 C.F.R. § 3.159 (b)(3) 2008. As the Veteran voiced disagreement with the assigned rating for the anxiety disorder in a notice of disagreement, no further duty to inform the Veteran of the requirements of VCAA exists. The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. The RO has properly processed the appeal following the issuance of the required notice. Moreover, all pertinent development has been undertaken, examination has been performed, and all available evidence has been obtained in this case. Thus, the content of the notice letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). No further action is necessary for compliance with the VCAA. During the pendency of this appeal, the Court in Dingess/Hartman found that the VCAA notice requirements applied to all elements of a claim. Additional notice as to these matters was provided in a letter sent to the Veteran in March 2006. The notice requirements pertinent to the issue addressed in this decision have been met and all identified and authorized records relevant to the matter have been requested or obtained. Further attempts to obtain additional evidence would be futile. The Board finds the available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to move forward with the claim would not cause any prejudice to the appellant. Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Where a claim for a higher evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings from the time the claim is file until VA makes a final decision. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. See 38 C.F.R. § 4.7. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service- connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14. General Rating Formula for Mental Disorders: Ratin g Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name 100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships 70 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships 50 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) 30 Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication 10 The Court has held that GAF scores are 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); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.) (DSM-IV), p. 32). The nomenclature employed in the schedule is based upon the DSM- IV, which includes the GAF scale. See 38 C.F.R. § 4.130. Global Assessment of Functioning (GAF) Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. 60 ? ?51 Moderate symptoms (e.g., flat affect and ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for anxiety disorder with alcohol abuse. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD G. Jackson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1950 to June 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by the RO. The Veteran and his wife testified before the undersigned Veterans Law Judge (VLJ) in a video-conference hearing in November 2009. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Anxiety disorder with alcohol abuse is shown to include no more than mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. CONCLUSION OF LAW The criteria for the assignment of an evaluation in excess of 10 percent for the service-connected anxiety disorder with alcohol abuse have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130 Diagnostic Code 9413 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled by information provided to the Veteran in correspondence from the RO dated in February 2006 and May 2008. Those letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claim and identified the Veteran's duties in obtaining information and evidence to substantiate his claim. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006). Effective May 30, 2008, 38 CFR 3.159 was revised to clarify that no duty to provide section 5103(a) notice arises "[u]pon receipt of a Notice of Disagreement" or when "as a matter of law, entitlement to the benefit claimed cannot be established."38 C.F.R. § 3.159 (b)(3) 2008. As the Veteran voiced disagreement with the assigned rating for the anxiety disorder in a notice of disagreement, no further duty to inform the Veteran of the requirements of VCAA exists. The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. The RO has properly processed the appeal following the issuance of the required notice. Moreover, all pertinent development has been undertaken, examination has been performed, and all available evidence has been obtained in this case. Thus, the content of the notice letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). No further action is necessary for compliance with the VCAA. During the pendency of this appeal, the Court in Dingess/Hartman found that the VCAA notice requirements applied to all elements of a claim. Additional notice as to these matters was provided in a letter sent to the Veteran in March 2006. The notice requirements pertinent to the issue addressed in this decision have been met and all identified and authorized records relevant to the matter have been requested or obtained. Further attempts to obtain additional evidence would be futile. The Board finds the available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to move forward with the claim would not cause any prejudice to the appellant. Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Where a claim for a higher evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings from the time the claim is file until VA makes a final decision. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. See 38 C.F.R. § 4.7. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service- connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14. General Rating Formula for Mental Disorders: Ratin g Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name 100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships 70 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships 50 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) 30 Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication 10 The Court has held that GAF scores are 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); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.) (DSM-IV), p. 32). The nomenclature employed in the schedule is based upon the DSM- IV, which includes the GAF scale. See 38 C.F.R. § 4.130. Global Assessment of Functioning (GAF) Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. 60 ? ?51 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Factual Background and Analysis In the appealed rating decision, the RO granted service connection for anxiety disorder with alcohol abuse and assigned a 10 percent rating for the anxiety disorder effective January 13, 2006, the date the claim for service connection was received. In May 2005, the Veteran sought treatment at the VA for a psychiatric disorder. His primary initial complaints were violent nightmares that occurred approximately six times per month and symptoms of anxiety and depression. He reported that he had experienced these symptoms for several decades (since his military service); however, he had not previously sought mental health treatment. He endorsed symptoms consistent with dissociative disorder, major depressive disorder, and alcohol abuse. He described experiencing dissociative episodes that occurred nearly daily when he would "zone out" and have intrusive thoughts, sometimes auditory hallucinations, about past experiences when he believed he was treated unfairly. The primary theme of his thoughts involved a belief that several former co- workers were out to get him. During the periods when he "zoned out" he heard these co-workers voices and he would speak back to them. He also thought about his time working on the cutter in the military. His wife reported that he would talk out loud and make unusual facial expressions. He was unaware of these dissociative episodes until his wife intervened. These dissociative episodes occurred daily and lasted anywhere from 15-30 minutes at a time. He denied other psychotic symptoms and repeated he only heard voices and saw visions in the context of these episodes. The examiner explained that the Veteran's behavior seemed to be most appropriately characterized as dissociative episodes with delusional thought content. The Veteran and his wife reported that he had experienced these dissociative episodes and nightmares for several decades. During the nightmares he yelled, struck out and occasionally fell out of bed. As a result he and his wife currently slept in separate rooms. In addition, he reported that he experienced a significant increase in depressive symptoms 15 years previously. With the increase in depressive symptoms, his dissociative episodes and nightmares also increased. He drank seven to ten beers and mixed drinks approximately every 4 days, in part to reduce his mood and anxiety symptoms. The examiner explained a definitive determination regarding a diagnosis of PTSD could not be made. It was possible that the Veteran's symptoms, including irritability and anxiety were related to the dissociation and depression. He was advised to initiate mental health treatment. The Veteran and his wife noted that they had a close, supportive relationship and were committed to each other. This had served as a major source of strength for him and had helped to ward of deteriorating functioning in the form of increased symptoms of psychological distress. He was diagnosed with dissociative disorder, not otherwise specified (NOS), recurrent major depressive disorder and alcohol abuse. He was assigned a GAF score of 50. In an August 2005 VA general mental health treatment record, the Veteran reported that he had no problems during the day; however, at night when he fell asleep, he had violent nightmares with episodes of acting out. He would holler, yell, scream ("help me, help me") and at times would attack his wife, leaving her with bruises. When he woke up, he had no recollection of these events. Every fourth day he would drink too much, up to 10 drinks. His dreams were not associated and mood was good during the day. Paxil did not make the symptoms worse. He had periods, once a week, where he would talk to his dead mother when he was awake. He denied symptoms of depersonalization, derealization or flashbacks. His childhood was unremarkable and he joined the Coast Guard at age 17. His first wife died after 29 years of marriage; they had three children. He had been married to his current wife for 22 years. After the military he worked as a meat cutter and had been retired for 10 years. He had few current hobbies; however, he did enjoy traveling, although his wife would not fly since 9-11. He had few close friends but was close with his wife. He was alert, oriented, casually dressed and well-groomed. He made good eye contact and had no abnormal movements. His speech was normal; mood was euthymic and affect congruent. Process was linear and goal oriented and content was reality- based. No delusions were evident and he had no suicidal or homicidal ideation. He denied having auditory or visual hallucinations. Insight and judgment were both good. He could not recall dreams or periods when he talked to people who have died. The examiner concluded that the Veteran's nightmares and acting out likely represented REM sleep behavior disorder. The Veteran also had noted excessive alcohol intake; however, his nighttime episodes were not associated with his alcohol intake. His periods of talking to the dead (his mother) during the day were associated with his alcohol intake. He denied significant mood dysregulation, though his wife noted he was less irritable on Paxil. The examiner noted the Veteran had a terrifying experience in service that he relived when exposed to certain triggers (movies, rough waters); however, he did not avoid stimuli and did not appear to have flashbacks, intrusive thought or recurrent dreams with consistent trauma content. The diagnoses were anxiety disorder, NOS, alcohol abuse, parasomnia, NOS (REM sleep behavior disorder). He was assigned a GAF score of 55. He was continued on his medication (Paroxetine) but it was indicated that the need for medication would be reevaluated once the sleep disorder stabilized and the alcohol abuse was addressed. Subsequent treatment records document his continued treatment for his psychiatric disorders and alcohol abuse. His assigned GAF scores ranged from 55-60. During a June 2007 VA examination, the Veteran reported that his first instance of psychiatric treatment was two years earlier when his wife convinced him to seek treatment for his terrible nightmares and associated acting out nightmares in his sleep which led to physical attacks of his wife. He would attack people in his dreams and sometimes fell to the floor. As a result of this behavior he and his wife slept separately. He believed his problems onset while serving on a cutter during his time in the service. During his service he was exposed to very stressful experiences and he believed these experiences were the cause of his bad dreams. The examiner documented the Veteran's history of treatment, noting that the Veteran was initially referred for a posttraumatic stress disorder (PTSD) assessment in 2005. In the initial treatment record, a definitive determination regarding a diagnosis of PTSD could not be made but he was diagnosed with dissociative disorder, NOS and recurrent major depressive disorder with alcohol abuse and assigned a GAF score of 50. The Veteran reported that he had difficulty finding a medication that was helpful; however, he was prescribed Trazodone at night that allowed him to get a good nights rest four nights out of the week. His wife reported that he had episodes when he would suddenly get angry and say "get out" or swear at her. These episodes occurred approximately four times per week; however, he had no recollection of these events. He also had no recollection of his dreams and only knew he was acting them out because he would end up on the floor or his wife would describe his behavior to him. His wife was distressed by his actions. His current dosage of Trazodone had been the best medication prescribed for his symptoms to date. The Veteran spent his time working in his yard and visiting with his grandchildren or watching television. He is an avid baseball fan. He regularly exercised and walked. He smoked for 60 years but reportedly quit six months ago. He had good family relationships and got along well with his wife children, grandchildren and great-grandchildren. His early family life was normal; he got along well with his family growing up. He dropped out of school after the 11th grade and joined the Coast Guard. During his service in the Coast Guard he was assigned to night watch duties that led to the initial manifestations of his anxiety disorder. During service he was treated for anxiety symptoms and he was eventually discharged. Subsequent to service he worked as a meat cutter and reported he had successful occupational functioning. He was unsure when his nightmares onset but believed that he had been having them for many years. He typically did not remember the content of his nightmares; however, he did remember feeling like someone was attacking him and he fought back. His dreams did not appear to be related directly to his experiences in the Coast Guard. Records indicated an REM sleep disorder, which could account for his acting out his dreams at night. His wife stated that she felt that he had "double personalities." At times he was "terrific" and at other times he was suddenly angry and cursing. She could not identify his triggers. The Veteran acknowledged that at times, he was irritable and would overreact in anger; however, his memory of these episodes was spotty. He had sleep difficulties partly due to his sleep apnea. He used a CPAP device which provided relief by allowing him to sleep through the night and feel well rested. He typically got about eight and one-half hours of sleep at night (sometimes more). He reported feeling hypervigilant (he always looked for exits whenever he went into a building); however, he generally had no difficulty going shopping or running errands with his wife. In general he was somewhat restless, tense and irritable; however, most of the time he enjoyed his family relationships and time spent with his grandchildren and great-grandchildren. He and his wife shared a close relationship and he had a history of successful occupational functioning. He felt depressed because he tended to worry. He described worry over members of his family. He denied any problems with his appetite and reported that he gained weight after he quit smoking. His energy level was generally adequate and he denied ever having any hopelessness or suicidal ideation. With regard to panic attacks, he described drifting off into "another world" when reading the paper because he had "too much on his mind." However, he was unsure if that was panic attacks or just generalized anxiety and worrying. He often socialized by going to the local VFW post and drinking while he was there. His wife was concerned about his drinking and he admitted to often drinking to excessive amounts. He denied any history of drug use and his wife closely monitored his medication regimen. The Veteran was casually and neatly dressed and groomed and appeared his stated age. His wife accompanied him to the examination room to report episodes where the Veteran had no recollection of events. He was appropriate and cooperative and had a pleasant and euthymic affect. He was somewhat tense and spoke with a mild stutter. There was no evidence of delusional processes and he denied having auditory or visual hallucinations. However, he reported that his wife described episodes where he spoke with his mother or a friend, both of whom were deceased (he had no recollection of these episodes). He felt his memory was fine. He was oriented to date, month, year and day of the week. He could spell the word "world" backwards and could count down from 100 by serial 7s (he did make one error but corrected the error when queried). He could adequately interpret three proverbs and could recall three out of four words after a brief intervening task. He could not remember the fourth word even when a hint was provided. He was competent for VA purposes. The diagnosis was anxiety disorder, NOS, dissociative disorder, NOS, parasomnia, NOS and alcohol abuse (Axis I). His stressors were mild to moderate related to coping with his chronic anxiety and sleep difficulty. He was assigned a GAF score of 60. The examiner noted that the Veteran had a long history of acting out violently in his sleep and being irritable and restless, with sudden mood changes, apparent dissociative episodes and alcohol abuse. He had a positive relationship with his wife and other family members and had a successful work history. He was able to participate in yard work and enjoyed following sports. It was likely that he experienced regular stressful episodes during his period of service and even had documented treatment for anxiety during service. He was considered not fit for sea duty and was recommended for shore duty his last two months of service. It was likely that he experienced a serious level of anxiety during his period of service. The Veteran did not seek any other type of treatment for sleep problems or any psychiatric symptoms until approximately 2005, based on the persuasion of his wife. His current medication, Trazodone, has been helpful in controlling his symptoms. He was not particularly distressed by his sleep difficulties because he was able to sleep through the night four nights a week and at other times did not remember his behavior; however, his behavior was stressful for his wife. Also, he was not bothered by his dissociative episodes because he had no recollection of the episodes; again, this was distressing for his wife. The examiner concluded that the anxiety disorder and alcohol abuse were likely related to his period of service; however, the dissociative disorder and parasomnia disorders were not related to his period of service. Given its review of the evidence of record, the Board finds that the Veteran's service-connected anxiety disorder with alcohol abuse is shown to be essentially productive of occupational and social impairment due to mild or transient symptoms and is controlled by continuous medication. In this regard, the Board notes that in the June 2007 VA examination, the Veteran was appropriate and cooperative throughout the examination and had a pleasant and euthymic affect. He was somewhat tense and spoke with a mild stutter but there was no evidence of delusional processes and he denied any auditory or visual hallucinations (although the wife reported he sometimes spoke to his mother and friend who were both deceased; he had no recollection of this). His memory was intact. He denied having any feelings of hopelessness or suicidal ideation. He had normal social functioning and had good relationships with his wife, children, grandchildren and great-grandchildren. He often socialized at the VFW, although he would consume alcohol to excess amounts at these events and had no reported difficulty with public places. He had successful occupational functioning and there was no indication that he had any problems, occupationally, prior to his retirement. He did get restless, tense and irritable; however his medication, Trazodone, offered relief of his symptoms. He had no complaints of sleep difficulties (four nights out of the week in slept in excess of eight hours); however, his wife did complain during the other nights he had violent nightmares (although the Veteran had no recollection of these events). The examiner concluded that his stressors were mild to moderate related to coping with his chronic anxiety and sleep difficulty. The examiner found that the Veteran's anxiety and alcohol abuse were related to his period of service but the dissociative disorder and parasomnia were unrelated to his period of service. The Veteran was not particularly distressed by his symptoms, including the apparent sleep disturbances; although, it was distressing to his wife. The Board is aware that the Veteran was assigned GAF scores ranging from 55-60 in the medical evidence of record. In this regard, GAF scores that range from 51-60 are assigned for PTSD with moderate symptoms. A disability evaluation shall be assigned based on all the evidence of record that bears on occupation and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination, or solely on the basis of social impairment. See 38 C.F.R. §§ 4.126 (2009). Although the Veteran's GAF score must certainly be considered in the evaluation of the service-connected anxiety disorder, it is not dispositive. Here the examiner found the Veteran's anxiety was mild to moderate and he is certainly qualified to offer this assessment. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). During the November 2009 Board hearing, the Veteran's wife testified that his symptoms were getting worse; mainly related to his nightmares and irritability; however, the Veteran testified that his medication relieved his symptoms and he slept through the night (he also used a CPAP machine for sleep apnea) and had no recollection of any nightmares. The wife testified that at times, the Veteran got irritable or cranky and she would go to her daughter's house. The Veteran did testify that he had daily anxiety attacks, especially if he watched a war movie because it reminded him of circumstances of his service. However, he continued to socialize with his friends a couple of times a week at the VFW, still had good relationships with his family members, had no difficulties in going out in public and had no reported occupational difficulties prior to his retirement after 42 years. Given the entire record in concert, it is concluded that the Veteran's anxiety symptoms are mild and controlled by continuous medication, therefore more nearly approximating the lower rather than the higher rating. To warrant an increased rating, the Veteran would have to exhibit such symptoms (in addition to anxiety) as depressed mood, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment and mild memory loss (such as forgetting names, directions or recent events). Such impairment, related to the service-connected anxiety, is simply not demonstrated by the record. For these reasons, an evaluation in excess of 10 percent is not warranted. 38 C.F.R. §§ 4.7, 4.130 DC 9413. In Thun v. Shinseki, F.3d 1366 (Fed. Cir. 2009), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must 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 is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, 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 the veteran's disability picture requires the assignment of an extraschedular rating. The Board finds that the disability is not so unusual or exceptional as to render impractical the application of the regular schedular standards at any time during the pendency of the initial evaluation period. 38 C.F.R. § 3.321(b)(1). In this regard, the Board notes that the veteran's anxiety disorder has not necessitated frequent periods of hospitalization and there is no objective evidence that it resulted in marked interference with his employment. The facts of this case do not present such an extraordinary disability picture such that the Board is required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra-schedular evaluations in "exceptional" cases. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Thun v. Peake, 22 Vet. App. 111, 115 (2008). ORDER An initial evaluation in excess of 10 percent for anxiety disorder with alcohol abuse is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs