Citation Nr: 1007940 Decision Date: 03/03/10 Archive Date: 03/11/10 DOCKET NO. 08-35 101 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an increased disability rating for generalized anxiety disorder, currently evaluated as 50 percent disabling. 2. Entitlement to an increased disability rating for hypertension, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Hinton, Counsel INTRODUCTION The Veteran served on active duty from April 1969 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York, which denied the benefits sought on appeal. At a December 2009 Travel Board hearing at the RO, the Veteran testified before the undersigned Veterans Law Judge about his symptoms resulting from his service-connected generalized anxiety disorder and hypertension. FINDINGS OF FACT 1. The evidence establishes that the Veteran's generalized anxiety disorder caused no more than occupational and social impairment, with deficiencies in most areas; near-continuous depression affecting his ability to function independently; impaired impulse control resulting in clear risk to employment; and difficulty in adapting to stressful circumstances including work. The evidence does not show total occupational and social impairment. 2. The veteran's hypertension results in diastolic pressure that is predominantly less than 110 and systolic pressure that is predominantly less than 200. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, the schedular criteria are met for a disability rating of 70 percent, and no more, for generalized anxiety disorder. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code 9400 (2009). 2. The criteria for an initial disability rating in excess of 10 percent for hypertension are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.104, Diagnostic Code 7101 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim, as well as what parts of that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Though notification to the Veteran may not have met all of the requirements of the VCAA and related case law, the matter decided below may be addressed at this time, without further remand, because no errors in notice are prejudicial, and the Veteran has been provided all information needed for a reasonable person to prove these claims. In any event, the Federal Circuit recently vacated the Court's previous decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), concluding that generic notice in response to a claim for an increased rating is all that is required. See Vazquez-Flores v. Shinseki, No. 08-7150 (Fed. Cir. Sep. 4, 2009). VA notified the Veteran of the information and evidence needed to substantiate and complete a claim by way of a letters dated in June 2007 and March 2008. These documents provided notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. The RO informed the Veteran of the specific rating criteria that would provide a basis for the rating claims on appeal and decided below. The RO has provided adequate notice of how effective dates are assigned. The claims were subsequently readjudicated most recently in an October 2008 statement of the case. To the extent the appellant did not receive full notice prior to the initial decision, after pertinent notice was provided, the claimant was afforded a meaningful opportunity to participate in the adjudication of the claim on appeal. In any event, the Veteran has never alleged how any content error prevented him from meaningfully participating in the adjudication of his claims. As such, he has not established prejudicial error in the content of VCAA notice. See Shinseki v. Sanders / Simmons, 129 S. Ct. 1696 (2009). The claimant was provided the opportunity to present pertinent evidence. The record contains service treatment and personnel records, and records of medical treatment received from VA, and VA examination reports. Findings from these examinations, and other medical records on file, are adequate for the purposes of deciding the claims on appeal. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no evidentiary indication that the conditions under review here have worsened since these evaluations so as to require any additional examination. In sum, there is no evidence of any VA error in notifying or assisting the appellant that reasonably affects the fairness of this adjudication. VA has fulfilled its duty to assist the claimant by obtaining identified and available evidence needed to substantiate the claims, and, as warranted by law. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Analysis Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2 . If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 . Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). When a disability is not specifically listed in the Rating Schedule, it may be rated under a closely related injury in which the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2009). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). If a veteran appeals a rating decision seeking an increased rating for a disability for which service connection has already been established, such as here with both claims on appeal, then the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). See also Hart v. Mansfield, 21 Vet. App. 505 (2007) (finding staged ratings appropriate also in cases where the appeal was not as to the initial rating assigned after service connection is established). Thus, in deciding the claim below, the Board has considered whether different ratings may be warranted for different time periods based on the evidence of record. Thus in deciding the claims below, the Board has considered whether different ratings may be warranted for different time periods based on the evidence of record. The Veteran's statements and testimony describing the symptoms of his service-connected disorders are deemed competent evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. A. Generalized Anxiety Disorder Currently, the RO has assigned the Veteran's generalized anxiety disorder a disability rating of 50 percent. The RO has assigned that rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9400, reflecting service connection for generalized anxiety disorder. According to 38 C.F.R. § 4.126(a), a mental disorder shall be evaluated "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 examination." 38 C.F.R. § 4.126(a) (2009). The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. The general rating formula for evaluating disability due to mental disorders is found at 38 C.F.R. § 4.130. The Veteran's generalized anxiety disorder, is rated under 38 C.F.R. § 4.130, Diagnostic Code 9400. Under that code, pursuant to the general rating formula, a 50 percent evaluation is warranted if evidence shows 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. A 70 percent evaluation is warranted if evidence shows 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 an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if evidence shows 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. Id. In rating the severity of the Veteran's service-connected psychiatric disability under the criteria listed above, the Board is aware of the fact that psychiatric health care providers have their own system for rating psychiatric disability. This is the Global Assessment of Functioning (GAF) rating scale, and it is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM- IV); Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DSM-IV. The GAF scale score assigned does not determine the disability rating VA assigns, however, it is one of the medical findings employed in that determination. The medical evidence shows a GAF score has been assigned during the pendency of this claim. An examiner's classification of the level of psychiatric impairment, by words or by a score, is to be considered but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. A GAF score, however, is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). The following applies regarding GAF scores relevant to this case: A GAF score of from 31 to 40 represents some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. These symptoms include speech which is at times illogical, obscure, or irrelevant; a person who is depressed and avoids friends, neglects family, and is unable to work. A GAF score from 41 to 50 is defined as serious symptoms or any serious impairment in social, occupational, or school functioning. A GAF score from 51 to 60 is defined as moderate symptoms, or moderate difficulty in social or occupational functioning. DSM- IV. The relevant medical evidence on file consists of records showing treatment by VA medical providers dated from 2005 to October 2008; and reports of VA examinations in January 2005, July 2007, and April 2008 . The following is a summary of representative medical evidence material to the Veteran's claim over the relevant period. The report of the January 2005 VA examination shows that the Veteran reported that he had not been hospitalized psychiatrically since his last VA examination, which was in May 2002. At the time of the examination he was married and employed. The Veteran reported he had seen a psychiatrist on a regular basis in the previous two years and was currently taking Klonopin and Celexa for his psychiatric disorder. The Veteran reported that he had been employed by the U.S. Postal Service since 1988. He reported having considerable ongoing difficulty at his job. The difficulty was primarily due to his temper outbursts and confrontations with supervisors and coworkers. The difficulty necessitated his taking frequent sick leave-several days a month, because of anxiety and depression, in addition to physical complaints regarding his left leg. He reported that since his last examination he was written up (discipline action) at least once, and received counseling, for losing his temper on the work floor. On examination the Veteran was casually dressed, appropriately groomed, alert, and oriented in all spheres. He made good eye contact and displayed behavior appropriate to the interview. His mood was anxious and depressed. He cried several times during the interview and his affect was generally sad. He denied suicidal or homicidal ideation. He displayed no impairment of communication or thought process. His speech was spontaneous, relevant and at a normal rate and rhythm. His thinking was logical, goal oriented, and without evidence of thought disorder. He denied hallucinations or delusions. He did not report having panic attacks, phobias, obsessive thoughts, or rituals interfering with functioning. He showed adequate maintenance of personal hygiene. He reported having chronic middle insomnia resulting in fatigue during the day. His long and short term recall were grossly intact. His attention and concentration were somewhat impaired but adequate. His judgment and insight were present. The examiner opined that a comorbid dysthymic disorder represented a progression of the Veteran's generalized anxiety disorder; and that although the Veteran's outpatient treating psychiatrist had diagnosed post-traumatic stress disorder, the Veteran did not appear to meet such criteria. After examination the report contains a diagnosis of generalized anxiety disorder, and dysthymic disorder, representing a progression of the generalized anxiety disorder. On Axis V, the report records a GAF score of 49, reflecting (symptoms of generalized anxiety disorder) frequent worry, impaired concentration, sleep disturbance, irritability, fatigue, restlessness; and (symptoms of dysthymic disorder) depressed mood, feelings of hopelessness, low self-esteem. The examiner estimated a GAF score of 48 to 53 for the past year. In a January 2005 addendum to the January 2005 VA examination, the examiner indicated that he had not had access to the claims file to review at the time of the January 2005 examination. The addendum contains essentially the same findings as contained in the earlier VA examination that month. The report of a July 2007 VA examination shows that the Veteran continued to have regular outpatient psychiatric treatment from a VA psychiatrist, and receiving medication, Bupropion and Lorazepam, which the Veteran reported to not be especially effective in regulating his anxiety. The Veteran reported having worked full time for the Postal Service for the last 18 years. He took two weeks of sick leave in 2006 after reported he was too stressed to work. He took another two weeks off in 2007 after an argument with a customer. His mother died in 2006 and this caused him considerable distress. The Veteran took extended sick leave in March 2007. The Veteran reported having sleep disturbance, which the examiner opined was more to do with sleep apnea than psychiatric symptoms. On examination, the Veteran was alert and oriented in all spheres. His mood was irritable, his affect was initially exaggerated and labile, but mostly controlled and pleasant during the interview. He denied suicidal and homicidal ideation. His speech and thought process were unimpaired. He spoke at a normal rate and rhythm with normal intonation. His thinking was logical and goal directed, without evidence of formal thought disorder. He did not report having hallucinations or delusions. His long and short term recall were grossly intact. His attention and concentration were adequate for interview purposes. The Veteran showed adequate hygiene. He reported no panic attacks, phobias, obsessive thoughts or rituals interfering with functioning. He denied any current substance abuse. His judgment and insight were present. After examination, the report contains an Axis I diagnosis of generalized anxiety disorder. The examiner recorded a GAF score of 60, reflecting irritability, worries about physical health, and relative social withdrawal. The examiner estimated the GAF score for the past year to be in the range of 55 to 61. VA treatment records in September 2007 show that the Veteran was seen at the VA emergency department with complaints that he told his boss at work he was feeling like killing someone. He was admitted from the VA emergency department for VA hospitalization in September 2007 for psychiatric treatment. During hospitalization, an inpatient psychosocial assessment report contains an admitting diagnosis on Axis I of PTSD, major depressive disorder, rule out alcohol abuse versus dependence. On Axis V, the GAF score was 40. An attending note by his treating psychiatrist contains an impression of severe PTSD with anniversary trigger, dysomnia. The report of an April 2008 VA examination shows that the Veteran reported some moderation of anxiety and anger with his current medications. The report records that the Veteran had problems at his job, including a recently ended suspension and short-lived removal from his position resulting from a verbal threat the Veteran made to his postmaster. The Veteran did not work from September 2007 to April 2008, pending multiple evaluations, hearings, and appeals. He was allowed to return to a different facility as a custodian on the condition that he sign a "last chance letter" and agree to regular counseling sessions. The report further records that the Veteran continued to live with his wife and two adult children, which whom he reported having loving relationships. The Veteran reported complaints that he had frequent irritability, impulsive anger, and frequent worry. The examiner characterized the Veteran's report of symptoms as having moderate symptoms daily. He reported that his unemployment from September to April was the direct result of his irritability associated with his generalized anxiety disorder. The Veteran reported that he had had no interpersonal problems or time off since his reinstatement one week before the present examination. In noting the effects of the Veteran's psychiatric condition on his social functioning, the examiner noted that the Veteran continued to harbor resentments against immigrants; limited his social interaction to his immediate family; and his temper outbursts continued unabated, with the consequences noted above regarding his job. On examination, the examiner made findings similar to that contained in previous examinations. The Veteran was casually dressed, appropriately groomed, alert and oriented in all spheres. His mood was anxious and irritable, and his affect congruent with his thought content. He did not report any suicidal or homicidal ideation. His speech and thought process were unimpaired. He spoke at a normal rate and rhythm with normal intonation. His thinking was logical and goal directed, without evidence of formal thought disorder. He did not report having any hallucinations or delusions. His long and short term memory was present. The examiner commented that the Veteran did not report symptoms fully consistent with a DSM-IV diagnosis of PTSD; and that any such symptoms of PTSD and impulse control disorder represented a continuation of the diagnosed generalized anxiety disorder. With respect to the effects of the mental disorder on occupational and social functioning, the examiner opined that the Veteran's psychiatric disorder resulted in reduced reliability and productivity due to mental disorder signs and symptoms. The report contains an Axis I diagnosis of generalized anxiety disorder; and on Axis V, a current GAF score of 51, reflecting anxiety, irritability, recent conflict on the job, and interpersonal conflicts. The examiner estimated the GAF score for the past year to be 45 to 60. VA treatment records during the relevant period show that the Veteran received outpatient psychiatric treatment for symptomatology diagnosed to include PTSD and generalized anxiety disorder. During numerous treatment visits, the treatment provider predominantly estimated a GAF score of 50. Findings included symptoms of periodic flashbacks, nightmares, and avoidance of Vietnam-related issues. Of record are a number of letters from the U.S. Postal Service to the Veteran dated between September 2007 and February 2008. These letters show that the Veteran was placed on an off duty status, effective from September 7, 2007 to continue until advised otherwise; that he was scheduled for a Fitness For Duty Examination in October 2007, and a follow-up examination in November 2007; that in January 2008 he was notified of a proposal to remove him from the Postal Service; and that in February 2008 he was notified that charges for the proposed removal were considered to be fully supported by the evidence and warranted his removal. All of these documents related to the charges against the Veteran related to his behavior that can be associated with his service-connected psychiatric disability. On review of the record, and after giving the Veteran the benefit of the doubt, the objective medical evidence is at least in equipoise as to whether the Veteran's service- connected generalized anxiety disorder results in symptomatology productive of occupational and social impairment with deficiencies in most areas, especially associated with work or relationships with anyone outside of his immediate family. Clearly the objective medical findings document that the disorder has resulted in serious impairment and an inability to establish and maintain effective relationships with respect to his job and occupational functioning. Clearly, as reflected in medical evidence showing an unqualified nexus between the Veteran's occupational difficulties and his psychiatric disability, his psychiatric disability has resulted in difficulty in adapting to stressful circumstances in the workplace, which has more than once placed his job in jeopardy and recently has nearly caused him the permanent loss of his job. While the Veteran does not exhibit the full basket and severity of symptoms identified in the schedular criteria for a 70 percent disability rating, the VA medical evidence showing a severity resulting in hospitalization, and other medical evidence as discussed above, tip the scale toward the finding that the Veteran's service-connected generalized anxiety disorder so impacts his social and industrial ability as to warrant a 70 percent rating throughout the period since he submitted his claim for increase. The examiner at the April 2008 VA examination opined that the Veteran's psychiatric condition resulted in "reduced reliability and productivity" consistent with a rating of only 50 percent. That examiner estimated the GAF score for the past year to be in the range of 45 to 60. That range is consistent with symptoms ranging from serious impairment (reflecting an inability to keep a job) to moderate symptoms (occasional panic attacks/conflicts wit peers or co-workers) over the past year. See Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM- IV). Findings from that VA examination are similar to those contained in the earlier July 2007 VA examination. In contrast, much of the remainder of the medical evidence of record reflects much more severe psychiatric symptoms. First, the findings at the earlier January 2005 VA examination include a current GAF score of 49, which reflects serious symptoms such as being unable to keep a job. Other medical records show that the Veteran was hospitalized for several days in September 2007, when the provider estimated a GAF score of 40, reflecting serious symptoms. Id. Throughout the relevant period, the Veteran's treatment providers have consistently estimated the GAF score to be 50, reflecting serious symptoms. Id. The Veteran has generalized anxiety disorder resulting in various symptomatology including findings of periodic flashbacks, nightmares, avoidance of Vietnam-related issues, anxiety, irritability, conflicts on the job, interpersonal conflicts, social withdrawal, frequent worry, impaired concentration, sleep disturbance, fatigue, restlessness, depressed mood, feelings of hopelessness, and low self- esteem. Non-medical evidence contained in U.S. Postal Service documents on file reflect that the psychiatric disability is associated with symptomatic behavior leaving the Veteran ever in clear jeopardy of permanently losing his job. Therefore, after resolving any reasonable doubt remaining in favor of the Veteran, and comparing the Veteran's symptoms to the provisions of the rating schedule, for the reasons discussed above, the criteria for a 70 percent rating for generalized anxiety disorder, are more nearly approximated. See 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2009). The objective medical evidence, the Veteran's statements and testimony regarding his symptomatology, and the work-related evidence of the Veteran's work difficulties, show a psychiatric disability that more nearly approximates that which warrants the assignment of a 70 percent disability rating. See 38 C.F.R. § 4.7; Hart, supra. A disability rating in excess of 70 percent, however, is not warranted since the disability picture does not meet or approximate the criteria for a 100 percent disability. See 38 C.F.R. § 4.130, Diagnostic Code 9400. In that regard, the evidence does not show total occupational and social impairment. There is no evidence that the Veteran's generalized anxiety disorder includes 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; or memory loss for names of close relatives, his own occupation or name. In addition, there is no showing, and no allegation, that the Veteran's psychiatric disability reflects so exceptional or so unusual a disability picture as to warrant referral for consideration of the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2009). There is no indication that the disability results in marked interference with employment (i.e., beyond that contemplated in the evaluation assigned here) for any period since the Veteran submitted his claim for an increase in rating. The condition does not exceed or even meet the criteria required for the maximum rating on a schedular basis. Moreover, the psychiatric condition is not shown to warrant frequent periods of hospitalization-there was only one during the relevant period-or to otherwise render impractical the application of the regular schedular standards. In the absence of evidence of such factors, the Board is not required to remand the claim to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In sum, the preponderance of evidence is against the claim for a disability rating in excess of the 70 percent granted here for service-connected generalized anxiety disorder. The benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied beyond that rating. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Hypertension Service connection is in effect for hypertension, for which the RO has assigned a 10 percent disability rating under 38 C.F.R. § 4.104, Diagnostic Code 7101. Under that diagnostic code, hypertension is evaluated pursuant to the following rating criteria: A 10 percent rating is warranted for hypertension for cases in which the diastolic pressure is predominantly 100 or more; or if the systolic pressure is predominantly 160 or more; or, this is the minimum evaluation for an individual with a history of diastolic pressure of predominantly 100 or more and who now requires continuous medication for control; and A 20 percent disability rating is warranted if the diastolic pressure is predominantly 110 or more; or the systolic pressure is predominantly 200 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. For VA purposes, hypertension is defined as diastolic blood pressure that is predominately 90 millimeters or greater or systolic blood pressure that is predominately 160 millimeters or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2009). Also, hypertension must be confirmed by readings taken 2 or more times on at least 3 different days. Id. The relevant medical evidence for review includes the report of a VA examination in January 2005; and VA treatment records dated from the early 2005 through October 2008, which contain numerous blood pressure readings and other findings pertaining to the Veteran's hypertension. The report of the January 2005 VA examination shows that the Veteran stated that his current treatment was to take Atenolol 5 mg. every day for his high blood pressure. On examination, blood pressure was measured three different times and each time recorded as 140/80. There were no signs of atherosclerotic complications secondary to hypertension. Electrocardiogram examination showed a normal sinus rhythm with no signs of left ventricle hypertrophy. After examination the report contains a diagnosis of hypertension, currently on medications; this does not interfere with his daily activity or occupation. The treatment records since 2005 record multiple blood pressure readings throughout the period from August 2006 to October 2008. Review of these treatment records reveals that the Veteran's hypertension resulted in diastolic pressure readings that were predominantly less than 110 and systolic pressure readings that were predominantly less than 200. In fact, the recorded diastolic pressure readings were essentially all less than 98, and the recorded systolic pressure readings were essentially all less than 151. Of the numerous blood pressure readings dated within one year prior to the present claim on appeal, there was only one diastolic pressure reading of 98, the rest being lower; and only one systolic pressure reading of 151, the rest being lower. Based on the foregoing, the preponderance of the evidence is against assignment of a disability rating in excess of 10 percent. The diastolic pressure has no been predominantly 110 or more; and the systolic pressure has not been predominantly 200 or more. Therefore, the criteria approximating the next higher rating of 20 percent have not been satisfied, and a higher evaluation for hypertension is therefore unwarranted under that criteria. In addition, there is no showing, and no allegation, that the Veteran's hypertension disability reflects so exceptional or so unusual a disability picture as to warrant referral for consideration of the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2009). At the time of the January 2005 VA examination, the examiner opined that the Veteran's hypertension did not interfere with his daily activity or occupation. The record since then does not show any significant worsening disability reflecting so exceptional or so unusual a disability picture as to warrant referral. In sum, the preponderance of evidence is against the claim for a disability rating in excess of 10 percent for service- connected hypertension. The benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A 70 percent rating is granted for generalized anxiety disorder, subject to the controlling regulations governing the payment of monetary benefits. A disability rating in excess of 10 percent for hypertension is denied. ____________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs