Citation Nr: 1037506 Decision Date: 10/04/10 Archive Date: 10/12/10 DOCKET NO. 07-12 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to an initial rating in excess of 10 percent for social phobia (paruresis). REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The appellant is a veteran who served on active duty from December 1973 to February 1976. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the New York, New York, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that prior to award of service connection for social phobia, the Veteran had perfected appeals in the issues of entitlement to service connection for dysthymic disorder and posttraumatic stress disorder (PTSD). As will be further discussed below, the RO advised the Veteran that the award of service connection for social phobia represented a complete grant of the benefits sought on appeal for psychiatric disability. The Board notes that, in addition to social phobia, the medical evidence of record shows that the Veteran has been diagnosed with anxiety disorder and dysthymic disorder (depression). The Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service- connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The medical evidence in this case does not provide a clear delineation of the symptoms attributable to each psychiatric diagnosis. As such, the Board will not make such a distinction and will treat all reported psychiatric symptomatology as being attributable to the service-connected social phobia, which is favorable to the Veteran. FINDING OF FACT Throughout the period of the appeal, the Veteran's service- connected psychiatric symptoms have been manifested by no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for social phobia (paruresis) have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9403 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (Apr. 30, 2008)). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). For the issue decided herein, the appeal is from the initial rating assigned with the grant of service connection. The statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, statutory notice has served its purpose, and its application is no longer required because the claim has already been substantiated. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006). The Veteran is exercising his right to appeal the rating assigned. An October 2009 statement of the case (SOC) and May 2010 supplemental SOC (SSOC) properly provided the Veteran notice of the criteria for rating psychiatric disabilities, as well as further notice on the downstream issue of an increased initial rating, including of what the evidence showed, and why the current rating was assigned. The Veteran has had ample opportunity to respond/supplement the record. He is not prejudiced by this process; notably, he does not allege that notice in this case was less than adequate or that he is prejudiced by any notice deficiency. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Goodwin v. Peake, 22 Vet. App. 128 (2008). Regarding VA's duty to assist, all appropriate development to obtain the Veteran's pertinent service treatment records (STRs) and post-service medical records has been completed. He did not identify any pertinent, outstanding treatment records. The RO arranged for a VA examination in 2003 and 2009. The Veteran (through his attorney representative in December 2009) indicated that he did not wish to participate in a hearing. Evidentiary development is complete. VA's duties to notify and assist are met. Accordingly, the Board will address the merits of the claim. Factual Background The STRs show that in April 1975, the Veteran was seen for complaints of difficulty urinating in the presence of others for six years and he requested a urological consultation despite a "GMO" opinion that the problem is psychological. The examiner indicated that the Veteran had a history of inability to void under public circumstances-a problem present prior to service-and was certainly worse in the Army. It was noted that recently he was unable to produce a drug urine sample. It was indicated that there was no history of genitourinary trauma or infection. The impression was detrusor/bladder dyssynergia. A June 1975 entry indicated that the Veteran was being investigated for inability to void publicly, specifically inability to produce a urine specimen for purposes of drug control. After examination, the examiner concluded that there was no objective evidence of voiding dysfunction. Post-service, St. Joseph's Hospital records dated in June 1993 and July 1994 show complaints of difficulty voiding. Multiple cystoscopies were performed. Private outpatient treatment records dated from October 1996 to January 2003 show complaints of inability to urinate in public and assessments of bashful bladder syndrome and benign prostate hypertrophy (BPH). In October 2002, the Veteran submitted a claim for service connection for an inability to urinate. On VA psychiatric examination in January 2003, the examiner noted that the Veteran was to be assessed for an original service connection for paruresis and indicated that the claims file was available at the time of evaluation. The Veteran's in-service and post-service history regarding urinary problems was noted. On examination, the Veteran complained of nervousness, irritability, frustration and anger. He reported sleeping difficulty throughout most of his adult life, to include taking an hour to fall asleep and then having five to six hours of broken sleep. He reported that he was divorced and had custody of his children. He reported that he had an excellent relationship with his children. He stated that he was too busy raising them to do much socially, but had done some dating. He enjoyed staying in touch with his family, exercising and watching educational television. He was working full time. Objectively, the examiner noted that the Veteran had a nervous demeanor. His motor function was within normal limits. His affect was somewhat blunted and his mood was "pretty good." Speech was within normal limits. The Veteran reported occasional suicidal ideation but no plan or intention of self harm. He denied homicidal ideation, delusions, or hallucinations. Memory, attention and concentration were "very good." Insight and judgment were fair. The Axis I (clinical disorders) diagnosis was anxiety disorder, not otherwise specified. The Axis III (general medical conditions) diagnosis was urinary problems, deferred to medical evaluation. The examination assigned a Global Assessment of Functioning (GAF) score of 65. The examiner stated that she could not comment as to whether or not the Veteran had a specific medical etiology for his urinary problems. It was indicated that if there was no medical etiology to the problem, then it would be suggested that his difficulty urinating had more to do with his anxiety. It was indicated that while anxiety was a component to the urinary problems, no answer could be stated as to whether or not the anxiety was the cause of the problem. VA outpatient treatment records dated from August 2003 to May 2006 show complaints of inability to urinate in public and diagnoses of paruresis, social phobia, depressive disorder, NOS and general anxiety disorder. During this time period the Veteran denied homicidal or suicidal ideation and speech was normal. There was no evidence of psychosis or memory loss. The Veteran was well groomed and oriented. He reported problems with depression and self esteem. He was participating in psychotherapy and taking medication. Of particular note, in January, February, May and June 2004, the Veteran reported fewer difficulties urinating in public places. In June 2004 he reported that he was not as afraid of rejection as he used to be. In August 2004 and January 2005, the Veteran reported periodic problems falling and staying asleep, but also noted that he worked out, had dinner and drank coffee after 10:00 PM and then went to bed after 11:00 PM. He also reported taking Ambien. In March 2005, the Veteran claimed he was functioning at work and taking care of his children. The examiner noted that paruresis was still an issue with possible response to therapy made less likely with the Veteran's intent of receiving VA compensation. In a May 2006 statement, a urologist indicated that the Veteran suffers from bashful bladder syndrome with considerable difficulty voiding in public. He also stated that while the condition was not life threatening, it had a "severe impact" on the Veteran socially. During a June 2006 Board hearing, the Veteran testified that during service, he was unable to provide a urine sample. The Veteran's representative noted that the Veteran had taken anti- depression medication following service, but was not currently taking that medication because of a bad reaction. A July 2009 VA psychiatric examination report reflects that the Veteran had worked as a carpenter for many years; he felt that he had done very well in his job but his difficulties urinating in public places had held him back in terms of his career. He indicated that he currently worked in a shop where there was a private bathroom instead of in the field. He also reported difficulty pursuing romantic relationships because he did not want to have to explain his condition. The Veteran reported that his two children lived with him and attended community college. He had only a few close friends. He was independent in all activities of daily living, and had no history of legal problems. The Veteran reported that he had discontinued his antidepressant medications because of the side effects and had dropped out of psychiatric treatment. He still took Ambien on occasion. He complained of depression and anxiety on most days, low energy and difficulty sleeping. He tended to avoid public or social situations. On examination, the Veteran was appropriately groomed and cooperative. His behavior was appropriate and there was no impairment of communication. His motor functioning was unremarkable. Mood was depressed and anxious. Affect was constricted. Speech was within normal limits. Thought process was organized and goal directed. He denied suicidal ideation, homicidal ideation, hallucinations, or periods of violence. The Veteran was alert and oriented times three. Recent and remote memory was intact. Insight and judgment were good. The diagnosis was social phobia. The examiner assigned a GAF score of 65. He noted that the Veteran was underemployed and socially withdrawn. By rating decision dated in July 2009, the RO granted service connection for social phobia (paruresis), evaluated as 10 percent disabling, effective October 11, 2002. In a July 2009 letter, the RO informed the Veteran that this award also represented a complete grant of the benefits sought on appeal relative to a July 2006 notice of disagreement (for the issues of entitlement to service connection for dysthymic disorder and PTSD). In a September 2009 Notice of Disagreement, the Veteran appealed the rating assigned for social phobia. In a December 2009 statement, the Veteran indicated that he was still employed as a "shop" carpenter; although he would have preferred to work in the field, his paruresis prevented this type of employment. The Veteran indicated that his disability had not worsened since the July 2009 VA examination. Increased Rating - Law and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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(West 2002); 38 C.F.R. § 4.1 (2009). When 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. Where (as here) the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). 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. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. The Veteran is currently assigned a 10 percent rating under Diagnostic Code 9403 for social phobia. See 38 C.F.R. § 4.130, Diagnostic Code 9403. Under 38 C.F.R. § 4.130, the following ratings may be assigned: 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 warrants a 100 percent rating. 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 warrants a 70 percent rating. 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 warrants a 50 percent rating. 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) warrants a 30 percent rating. 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 warrants a 10 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9403 (2009). In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). 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. 70 ? ? 61 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft THE ISSUE Entitlement to an initial rating in excess of 10 percent for social phobia (paruresis). REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The appellant is a veteran who served on active duty from December 1973 to February 1976. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the New York, New York, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that prior to award of service connection for social phobia, the Veteran had perfected appeals in the issues of entitlement to service connection for dysthymic disorder and posttraumatic stress disorder (PTSD). As will be further discussed below, the RO advised the Veteran that the award of service connection for social phobia represented a complete grant of the benefits sought on appeal for psychiatric disability. The Board notes that, in addition to social phobia, the medical evidence of record shows that the Veteran has been diagnosed with anxiety disorder and dysthymic disorder (depression). The Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service- connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The medical evidence in this case does not provide a clear delineation of the symptoms attributable to each psychiatric diagnosis. As such, the Board will not make such a distinction and will treat all reported psychiatric symptomatology as being attributable to the service-connected social phobia, which is favorable to the Veteran. FINDING OF FACT Throughout the period of the appeal, the Veteran's service- connected psychiatric symptoms have been manifested by no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for social phobia (paruresis) have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9403 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (Apr. 30, 2008)). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). For the issue decided herein, the appeal is from the initial rating assigned with the grant of service connection. The statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, statutory notice has served its purpose, and its application is no longer required because the claim has already been substantiated. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006). The Veteran is exercising his right to appeal the rating assigned. An October 2009 statement of the case (SOC) and May 2010 supplemental SOC (SSOC) properly provided the Veteran notice of the criteria for rating psychiatric disabilities, as well as further notice on the downstream issue of an increased initial rating, including of what the evidence showed, and why the current rating was assigned. The Veteran has had ample opportunity to respond/supplement the record. He is not prejudiced by this process; notably, he does not allege that notice in this case was less than adequate or that he is prejudiced by any notice deficiency. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Goodwin v. Peake, 22 Vet. App. 128 (2008). Regarding VA's duty to assist, all appropriate development to obtain the Veteran's pertinent service treatment records (STRs) and post-service medical records has been completed. He did not identify any pertinent, outstanding treatment records. The RO arranged for a VA examination in 2003 and 2009. The Veteran (through his attorney representative in December 2009) indicated that he did not wish to participate in a hearing. Evidentiary development is complete. VA's duties to notify and assist are met. Accordingly, the Board will address the merits of the claim. Factual Background The STRs show that in April 1975, the Veteran was seen for complaints of difficulty urinating in the presence of others for six years and he requested a urological consultation despite a "GMO" opinion that the problem is psychological. The examiner indicated that the Veteran had a history of inability to void under public circumstances-a problem present prior to service-and was certainly worse in the Army. It was noted that recently he was unable to produce a drug urine sample. It was indicated that there was no history of genitourinary trauma or infection. The impression was detrusor/bladder dyssynergia. A June 1975 entry indicated that the Veteran was being investigated for inability to void publicly, specifically inability to produce a urine specimen for purposes of drug control. After examination, the examiner concluded that there was no objective evidence of voiding dysfunction. Post-service, St. Joseph's Hospital records dated in June 1993 and July 1994 show complaints of difficulty voiding. Multiple cystoscopies were performed. Private outpatient treatment records dated from October 1996 to January 2003 show complaints of inability to urinate in public and assessments of bashful bladder syndrome and benign prostate hypertrophy (BPH). In October 2002, the Veteran submitted a claim for service connection for an inability to urinate. On VA psychiatric examination in January 2003, the examiner noted that the Veteran was to be assessed for an original service connection for paruresis and indicated that the claims file was available at the time of evaluation. The Veteran's in-service and post-service history regarding urinary problems was noted. On examination, the Veteran complained of nervousness, irritability, frustration and anger. He reported sleeping difficulty throughout most of his adult life, to include taking an hour to fall asleep and then having five to six hours of broken sleep. He reported that he was divorced and had custody of his children. He reported that he had an excellent relationship with his children. He stated that he was too busy raising them to do much socially, but had done some dating. He enjoyed staying in touch with his family, exercising and watching educational television. He was working full time. Objectively, the examiner noted that the Veteran had a nervous demeanor. His motor function was within normal limits. His affect was somewhat blunted and his mood was "pretty good." Speech was within normal limits. The Veteran reported occasional suicidal ideation but no plan or intention of self harm. He denied homicidal ideation, delusions, or hallucinations. Memory, attention and concentration were "very good." Insight and judgment were fair. The Axis I (clinical disorders) diagnosis was anxiety disorder, not otherwise specified. The Axis III (general medical conditions) diagnosis was urinary problems, deferred to medical evaluation. The examination assigned a Global Assessment of Functioning (GAF) score of 65. The examiner stated that she could not comment as to whether or not the Veteran had a specific medical etiology for his urinary problems. It was indicated that if there was no medical etiology to the problem, then it would be suggested that his difficulty urinating had more to do with his anxiety. It was indicated that while anxiety was a component to the urinary problems, no answer could be stated as to whether or not the anxiety was the cause of the problem. VA outpatient treatment records dated from August 2003 to May 2006 show complaints of inability to urinate in public and diagnoses of paruresis, social phobia, depressive disorder, NOS and general anxiety disorder. During this time period the Veteran denied homicidal or suicidal ideation and speech was normal. There was no evidence of psychosis or memory loss. The Veteran was well groomed and oriented. He reported problems with depression and self esteem. He was participating in psychotherapy and taking medication. Of particular note, in January, February, May and June 2004, the Veteran reported fewer difficulties urinating in public places. In June 2004 he reported that he was not as afraid of rejection as he used to be. In August 2004 and January 2005, the Veteran reported periodic problems falling and staying asleep, but also noted that he worked out, had dinner and drank coffee after 10:00 PM and then went to bed after 11:00 PM. He also reported taking Ambien. In March 2005, the Veteran claimed he was functioning at work and taking care of his children. The examiner noted that paruresis was still an issue with possible response to therapy made less likely with the Veteran's intent of receiving VA compensation. In a May 2006 statement, a urologist indicated that the Veteran suffers from bashful bladder syndrome with considerable difficulty voiding in public. He also stated that while the condition was not life threatening, it had a "severe impact" on the Veteran socially. During a June 2006 Board hearing, the Veteran testified that during service, he was unable to provide a urine sample. The Veteran's representative noted that the Veteran had taken anti- depression medication following service, but was not currently taking that medication because of a bad reaction. A July 2009 VA psychiatric examination report reflects that the Veteran had worked as a carpenter for many years; he felt that he had done very well in his job but his difficulties urinating in public places had held him back in terms of his career. He indicated that he currently worked in a shop where there was a private bathroom instead of in the field. He also reported difficulty pursuing romantic relationships because he did not want to have to explain his condition. The Veteran reported that his two children lived with him and attended community college. He had only a few close friends. He was independent in all activities of daily living, and had no history of legal problems. The Veteran reported that he had discontinued his antidepressant medications because of the side effects and had dropped out of psychiatric treatment. He still took Ambien on occasion. He complained of depression and anxiety on most days, low energy and difficulty sleeping. He tended to avoid public or social situations. On examination, the Veteran was appropriately groomed and cooperative. His behavior was appropriate and there was no impairment of communication. His motor functioning was unremarkable. Mood was depressed and anxious. Affect was constricted. Speech was within normal limits. Thought process was organized and goal directed. He denied suicidal ideation, homicidal ideation, hallucinations, or periods of violence. The Veteran was alert and oriented times three. Recent and remote memory was intact. Insight and judgment were good. The diagnosis was social phobia. The examiner assigned a GAF score of 65. He noted that the Veteran was underemployed and socially withdrawn. By rating decision dated in July 2009, the RO granted service connection for social phobia (paruresis), evaluated as 10 percent disabling, effective October 11, 2002. In a July 2009 letter, the RO informed the Veteran that this award also represented a complete grant of the benefits sought on appeal relative to a July 2006 notice of disagreement (for the issues of entitlement to service connection for dysthymic disorder and PTSD). In a September 2009 Notice of Disagreement, the Veteran appealed the rating assigned for social phobia. In a December 2009 statement, the Veteran indicated that he was still employed as a "shop" carpenter; although he would have preferred to work in the field, his paruresis prevented this type of employment. The Veteran indicated that his disability had not worsened since the July 2009 VA examination. Increased Rating - Law and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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(West 2002); 38 C.F.R. § 4.1 (2009). When 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. Where (as here) the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). 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. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. The Veteran is currently assigned a 10 percent rating under Diagnostic Code 9403 for social phobia. See 38 C.F.R. § 4.130, Diagnostic Code 9403. Under 38 C.F.R. § 4.130, the following ratings may be assigned: 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 warrants a 100 percent rating. 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 warrants a 70 percent rating. 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 warrants a 50 percent rating. 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) warrants a 30 percent rating. 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 warrants a 10 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9403 (2009). In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). 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. 70 ? ? 61 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships. 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). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency 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). When evaluating the level of disability from a mental disorder, the rating agency 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). Analysis Regarding the application of the pertinent criteria, there is evidence of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress. The Board acknowledges the Veteran's report that he was uncomfortable in public and social situations. However, he also reported having some meaningful relationships with his children and a few close friends, as noted on 2003 and 2009 VA examination reports. While he has not accepted promotions to work in the field because of his social phobia, the fact remains that he has worked steadily for many years and, by his own report, has done a good job. The Board notes that the Veteran's GAF score was 65 in 2003 and 2009 based on VA examinations. A GAF score of 65 contemplates mild symptoms. While GAF scores are not, in and of themselves, the dispositive element in rating a disability, they are persuasive evidence when used in association with detailed evaluations. In this case the 10 percent rating contemplates a GAF score of 65 and a mild level of social phobia. Because, as noted, the evidence did not warrant greater than the 10 percent disability awarded, a higher evaluation is not warranted for any point during the appeal period. A 30 percent award is not warranted because there is no evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to depressed mood, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). As noted above, the Veteran has never exhibited any signs of memory loss. No panic attacks or suspiciousness have ever been reported. While the Veteran complained of periodic problems sleeping, this has been attributed to his exercising, eating and drinking coffee shortly before going to sleep, and not his social phobia. See August 2005 and January 2005 VA outpatient treatment reports. Moreover, while the Veteran's private urologist stated in 2006 that the Veteran's social phobia had a "severe" impact on him socially, the evidence simply does not demonstrate this. The Board appreciates the Veteran's difficulties using public restrooms. However, while he has experienced depressed mood, his depression has not been shown to interfere with his work efficiency or taking care of his children. Again, while he may not have many close friends, he stated on VA examination in 2009 that he did have some close friends. In sum, the Board finds that the criteria for a rating higher than the assigned 10 percent disability rating have not been demonstrated. The Veteran's symptoms are more akin to those criteria, not to the criteria for the 30 percent rating. The evidence of record shows that the Veteran's social phobia was improving with treatment. See 2004 VA outpatient treatment record. Thereafter, the Veteran decided to stop taking medication and receiving treatment. The last VA compensation examination was in July 2009, relatively recently. In a December 2009 statement, the Veteran denied that his disability had worsened since that time. Consequently, another examination to evaluate the severity of this condition is not warranted because there is sufficient evidence, already of record, to fairly decide this claim insofar as assessing the severity of this condition. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Olsen v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); and Allday v. Brown, 7 Vet. App. 517, 526 (1995). Consideration has also been given regarding whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra- schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2009). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation in this case is not inadequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected disability at issue, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. Moreover, the evidence does not demonstrate other related factors. Therefore, referral for extra-schedular consideration in this case is not in order. ORDER An initial rating in excess of 10 percent for social phobia (paruresis) is denied. ____________________________________________ ERIC S. LEBOFF Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs