Citation Nr: 1134870 Decision Date: 09/19/11 Archive Date: 09/23/11 DOCKET NO. 07-01 520 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for infection. 3. Entitlement to service connection for paroxysmal atrial fibrillation, to include as secondary to service-connected anxiety disorder. 4. Entitlement to an initial rating in excess of 50 percent for an anxiety disorder. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from October 1969 to July 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in August 2005, December 2006, and June 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In May 2011, the Veteran testified during a video conference Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. At the time of the hearing, the Veteran submitted additional material and waived initial RO consideration of this evidence. The Board accepts this additional evidence for inclusion in the record. See 38 C.F.R. § 20.800 (2010). During the Board hearing, the Veteran and his representative withdrew his appeal for service connection for PTSD and for service connection for infection and stated that any other claim for service connection for a heart condition not specifically noted at the hearing was to be encompassed in his current claim for service connection for atrial fibrillation. These issues as characterized at the video conference Board hearing are reflected on the title page and adjudicated below. The issue of entitlement to service connection for paroxysmal atrial fibrillation, to include as secondary to service-connected anxiety disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. In May 2011, prior to the promulgation of a decision, the Veteran withdrew his appeal pertaining to the claim of entitlement to service connection for PTSD. 2. In May 2011, prior to the promulgation of a decision, the Veteran withdrew his appeal pertaining to the claim of entitlement to service connection for infection. 3. For the period from January 20, 2004, when service connection for an anxiety disorder became effective, the evidence does not show that the Veteran's anxiety disorder results in occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal regarding the claim of entitlement to service connection for PTSD have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2010). 2. The criteria for withdrawal of a Substantive Appeal regarding the claim of entitlement to service connection for infection have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2010). 3. The criteria for an initial rating in excess of 50 percent for an anxiety disorder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.321, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9413 (2010). (CONTINUED ON THE FOLLOWING PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal of Claims Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In his Board testimony in May 2011, the Veteran stated his intention to withdraw his claims of entitlement to service connection for PTSD and for service connection for infection. These withdrawals have been reduced to writing in the transcript of the hearing associated with the claims file and in a document submitted to the Board after the hearing and signed by the Veteran and his representative. No allegations of errors of fact or law, therefore, remain for appellate consideration regarding these two issues. Accordingly, the Board does not have jurisdiction to review the appeal of these claims, and they are dismissed. VCAA 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 letters from the RO dated in May 2005, March 2006, January 2008, and December 2010. These 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, 20 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009)). Thereafter, the Veteran was granted service connection for an anxiety disorder and assigned an initial disability rating and effective date. As this claim was more than substantiated in that it was proven, the purpose that the notice is intended to serve has been fulfilled and no additional notice is required for this claim. Dingess, 19 Vet. App. at 490-91. Pursuant to Dingess, an additional notice as to disability ratings and effective dates was provided in the correspondence dated in March 2006, January 2008, and December 2010. In addition, since the higher initial rating claim for an anxiety disorder is a "downstream" issue from that of service connection, notice pursuant to the original Court decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), was never required for this issue. See VAOPGCPREC 8- 2003 (Dec. 22, 2003). In any event, the Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In view of the above, the Board finds that the notice requirements pertinent to the issue on appeal have been met. The duty to assist also has been fulfilled as VA and private medical records relevant to this claim have been requested and obtained and the Veteran has been provided with VA examinations. The Board finds that the available medical evidence is sufficient for an adequate determination of the claim on appeal. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with this claim would not cause any prejudice to the Veteran. Increased Rating - Laws and Regulations Disability ratings are determined by the application of 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 (2010). 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). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in 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 (2010). 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 are prohibited. 38 C.F.R. § 4.14 (2010). As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As a layperson the Veteran is only competent to report observable symptoms, but not the clinical findings which are applied to VA's Rating Schedule. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2010). 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 (2010). The Veteran's anxiety disorder rating has been adjudicated pursuant to the rating criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9413 (2010). Under that code and the General Rating Formula for Mental Disorders, ratings may be assigned ranging between 0 and 100 percent. A 50 percent disability rating requires 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. Id. A 70 percent rating requires 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 work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires 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. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the evaluation must be 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). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a) (2010). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates 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). Anxiety Disorder Historically, the Veteran was granted service connection for an anxiety disorder in an August 2005 rating decision and awarded a 30 percent disability rating, effective January 20, 2004, the date the Veteran's service connection claim for an anxiety disorder was received at the RO. He appealed this initial rating in a November 2005 Notice of Disagreement, or within 12 months of being granted service connection for an anxiety disorder. Subsequently, in the December 2006 rating decision now on appeal his initial disability rating for an anxiety disorder was increased from 30 percent to 50 percent, effective January 20, 2004. In a June 2007 Notice of Disagreement, the Veteran contended that his initial disability rating should be higher, at least 70 percent. The Veteran underwent a VA mental examination in July 2005. The Veteran complained of chronic problems with anxiety since two incidents in service during which a soldier sexually assaulted him and then another U.S. soldier shot other soldiers in camp, including two close friends of the Veteran. He said that his symptoms had worsened as he grew older, including sleeping problems, excessive worrying, hypervigilance, irritability, panic attacks, and an inability to relax. He reported that he had worked for Union Carbide, now Cryogenics, as a welder and pipe fitter, for the past 28 years. He was married to his second wife for 27 years. He had two children from his first marriage and two from his current marriage and enjoyed a good relationship with all. The Veteran denied any history of drug or alcohol abuse or any legal problems. On mental status examination, the Veteran was alert and oriented times four, was appropriately groomed, and demonstrated good personal hygiene. He was noted as obviously very anxious and nervous throughout the examination. He became tearful, more agitated, and developed a tic in his left eye when he began discussing his traumatic experiences in Vietnam. His mood was described as anxious; affect was congruent; thought content and processes were within normal limits; and no inappropriate behavior was noted. There was no evidence of delusions or hallucinations or gross memory loss or impairment and he denied suicidal or homicidal ideation. His speech was coherent and of a normal rate and volume. It was noted that the Veteran was not currently receiving any psychiatric treatment and had not received any treatment since he was discharged from military service. Diagnosis was generalized anxiety disorder with a GAF score of 51 assigned. The VA psychologist opined that the Veteran's anxiety was a result of his sexual assault in service and his witnessing the death of his two friends in Vietnam. The Veteran underwent a VA mental examination in July 2008. The Veteran complained of anxiety on a daily basis, constant restlessness and being fatigued as a result of sleeping difficulties, and occasional feelings of depression and helplessness. The examiner noted that his depressive feelings appeared more associated with his anxiety than a separate diagnosis in and of itself. The Veteran said that sometimes he was afraid to go to work at 5 a.m. because it was still dark out and he was afraid of being attacked. He included in the claims file a three-month period of his schedule which showed that at times he went to work at 7 a.m. rather than 5 a.m. because of his fearfulness. He denied working a swing shift, but said that he had been verbally reprimanded at times for being late for work. It was noted that the Veteran was afraid to go out when dark because he was fearful of being attacked. For example, he ran to the mailbox in the morning to retrieve the paper. He said that this arose from his sexual attack in Vietnam. It also was noted that the Veteran was obsessively worried about his youngest son's safety although he was less obsessive when his son was away at school. On mental status examination, the Veteran was oriented to person, place, time and situation. Psychomotor activity and speech functions were within normal limits and eye contact was intermittent. Thought content was mildly concrete and thought processes were goal-directed. He denied hallucinations and delusions. He described his mood as anxious and on edge. He appeared somewhat anxious with a congruent affect. Personal hygiene and grooming were adequate. Insight was marginal concerning his symptoms and judgment was functional. Memory functions were grossly intact with respect to recent and remote recall. He denied suicidal or homicidal ideation. The examiner noted that the Symptom Trauma Inventory test suggested that the Veteran over-reported or over-stated symptomatology. Diagnosis was a generalized anxiety disorder with a GAF score of 55 assigned. She opined that this anxiety disorder adversely affected his psychosocial and occupational functioning and quality of life to a moderate degree. She noted that he preferred isolative tasks and admitted to emotional sensitivity. She stated that the Veteran said he had no friends but was quite close to his wife. Insight was marginal concerning his symptomatology and judgment appeared functional. The examiner also opined that the Veteran's prognosis was guarded because of the chronicity of his symptoms, his advanced age, and virtually no treatment. The Veteran underwent a private psychological evaluation in September 2009 by L.S.L., Ph.D. Current symptoms included: "living in fear;" severe distrust of African Americans; easy startle; fear of strangers; inability to empty the garbage at night; intrusive thoughts about traumatic events in Vietnam; racing heart, palpitations, and panic attacks on a weekly basis. Diagnosis was PTSD with an assigned GAF score of 50. The Veteran underwent an initial VA examination for PTSD for more than two hours in October 2010. He described panic attacks every morning when he got up to go to work. He also complained of sleep difficulties, including a recurring dream twice a week. The Veteran also claimed that he was "living a lot in fear right now" because he was scared of African Americans since a black service member had sexually molested him a knifepoint in Vietnam. He described these symptoms as of mild to moderate severity since service and denied taking any medications for his anxiety. It was noted that the Veteran worked full-time as a welder and pipe fitter for the past 32 years and that work was going very well. On mental status examination, the Veteran was noted as fully oriented, well-groomed and cooperative. His mood was described as mildly anxious with full and reactive affect. He denied suicidal intent or planning, homicidal ideation, hallucinations, and delusions. Attention, memory, and judgment appeared to be within normal limits. Diagnosis was generalized anxiety disorder with a GAF score of 75 assigned. However, this GAF score was based only on objectively assessed PTSD symptomatology. A PTSD diagnosis was not given because the Veteran's documented mental health history and the results of objective testing did not conform to the DSM-IV guidelines for the diagnosis of PTSD. In statements dated in November 2010 and May 2011, the Veteran said that he thought his anxiety disorder met the criteria for a 70 percent rating for the following reasons: when he went to work he had panic attacks every day; he cannot deal with any kind of stress; his first wife left him due to his anxiety and his current wife was having a hard time staying; he was put on medication because of his moods; he cannot function independently without help and medications; and he has problems sleeping and gets up to check the doors and windows. The Veteran was provided a VA mental examination in January 2011. It was noted that the Veteran was not taking medications for any mental disorder but was receiving individual counseling at the Vet Center. The Veteran complained that he had "a hard time enjoying life right now." He told the examiner that all he essentially did was go to work and come home. He also said that when he got anxious leaving home or leaving work his palms got sweaty, his hand shook, and his heart "started racing real hard and fast." He also said that sometimes he called his youngest son three or four times a day and got real worried if he could not find him. He also admitted to an outburst at work the year before that he felt unable to control when he threw chairs and dumped over garbage cans. On mental examination, the Veteran was oriented to person, place, and time. His thought process and content were noted as unremarkable. His general appearance and affect were appropriate and his speech was spontaneous, clear and coherent. He denied delusions, hallucinations, and suicidal and homicidal thoughts. A sleep impairment with nightmare was noted and his hypervigilant checking of windows and doors at night was described as obsessive or ritualistic behavior. While his remote memory was normal, his recent and immediate memory were described as mildly impaired. It also was noted that the Veteran had lost an estimated two to three weeks from work during the past year because of his anxiety. Diagnosis was generalized anxiety disorder and a GAF score of 52 was assigned. The VA examiner also opined that the Veteran's symptomatology was fairly consistent with his July 2008 VA examination. She also opined that the Veteran's symptoms were most consistent with the criteria for reduced reliability and productivity, or the criteria for his current 50 percent disability rating. An April 2011 VA medical record showed a recent psychiatric consultation after a referral from the Vet Center and his VA primary care provider for evaluation and treatment of anxiety. He complained of recurrent nightmares of sexual assault about twice a week, anxious difficulties leaving home, panic attacks, and poor sleep. He also complained of depressed feelings, passive morbid thoughts, poor concentration, and a residual fear of young male African Americans. On mental status examination, the Veteran was noted as oriented to person, place, time and situation. An anxious and subdued affect and mood were noted, but the Veteran denied suicidal and homicidal ideations and hallucinations as well as obsessions and compulsions. Diagnosis was PTSD and panic disorder with agoraphobia. A GAF score of 48 was assigned. The VA psychiatrist also noted two prescriptions for anxiety. In a May 2011 letter from T.B., a licensed certified social worker at the Mobile, Alabama Vet Center, it was disclosed that the Veteran had been a client since April 2004 and was currently being seen in individual counseling to address his complaint of PTSD as a result of military sexual trauma, more consistently within the past three years. She stated that the Veteran had all the symptoms of PTSD along with a history of untreated severe depression and severe anxiety. She stated that he planned to remain in treatment at the Vet Center for weekly individual counseling and at the VA mental health clinic for psychiatric treatment and medication monitoring. The Veteran testified during a videoconference Board hearing in May 2011 that he was having a lot of problems and led a miserable life. He said that his symptoms had worsened and he was recently prescribed medication because he was having a lot of panic attacks. He said that he had been in counseling since 2004. He found it stressful to leave his home to go to work and felt like a prisoner in his own house, but was essentially ok at work during the day. The Veteran testified that besides being hypervigilant about the house he had bought high fluorescent lights to keep his house lit up at night. He also said that he thought that he met a lot of the symptoms described in the criteria for a 70 percent rating because of his isolation and family difficulties. He stated that his first wife divorced him because of all his problems, but his current wife had been very sympathetic and had stuck by him. (See transcript at pp. 3, 5, 7, 11, 12). Given the evidence of record, the Board finds that the Veteran does not warrant an initial disability rating in excess of 50 percent for his anxiety disorder. Numerous symptoms listed in Diagnostic Code 9413 for a 70 percent rating were not met during this period. For example, there is no evidence that the Veteran neglected his personal appearance and hygiene. He rather was described as appropriately groomed in all the VA examinations of record. There also is no evidence that his speech was intermittently illogical, obscure, or irrelevant. While there is evidence noting obsessive checking of windows and doors at night, there is no evidence of obsessional rituals which actually interfere with his routine activities. The Veteran has always denied suicidal and homicidal ideation or thoughts. There was no evidence of spatial disorientation and, in fact, the Veteran was oriented to person, place, and time during his VA examinations of record. There also is no evidence of difficulty in adapting to stressful circumstances. The most recent medical evidence for the period showed that the Veteran had worked full time as a welder and pipe fitter at the same company for more than 30 years and that he had good relationships with his wife and adult children. The Board acknowledges that there is some evidence that the Veteran manifested a few of the symptoms listed in Diagnostic Code 9413 for a 70 percent disability rating. While a Vet Center social worker wrote in May 2011 that the Veteran had severe, pervasive, and chronic depression, none of the VA mental examinations of record provided a depression diagnosis. The Veteran has provided evidence of nearly daily panic attacks when he prepared to leave home for work and leave work for home. While this could be taken as indicating that he has near-continuous panic or depression, there is no evidence that such affected his ability to function independently, appropriately, and effectively working full time as a welder for more than 30 years. There is also some evidence of impaired impulse control when the Veteran started throwing chairs and garbage cans at work on one occasion last year. However, there is no other evidence of violence against people or property during the period on appeal. The Board also acknowledges that some of the Veteran's self-reported symptoms during the period are not listed in Diagnostic Code 9413 for a disability rating of 70 percent or greater. These symptoms include, nightmares, reliving past experiences, and fear of African American males. Such symptoms concededly caused some occupational and social impairment. However, they are not of the type and degree indicative of such impairment with deficiencies in most areas. The symptoms manifested are at best, after affording the Veteran the benefit of the doubt, commensurate with the assigned 50 percent disability rating. Indeed, most of the Veteran's GAF scores during this time period reveal a level of functioning that does not comport with the criteria contemplated by the assignment of a 70 percent disability rating. With the exception of a 48 assigned in April 2011, a 50 assigned in September 2009, a 51 in July 2005, and a 75 assigned for PTSD symptoms in October 2010, these GAF scores are indicative of moderate symptoms or some difficulty in functioning, which are well within the criteria for the assigned 50 percent rating. His lower GAF scores are also borderline between indicating moderate or serious mental health symptoms. In sum, the Board finds that the anxiety symptoms manifested by the Veteran for the period on appeal are most similar to those contemplated by the criteria for a 50 percent disability rating. The Veteran did not manifest most of the symptoms listed in Diagnostic Code 9413 for a 70 percent rating. There is some evidence suggesting that he manifested a few of the other symptoms listed, but overall the evidence is against the assignment of a rating in excess of 50 percent for the reasons set forth above. As such, the Board finds that the preponderance of the evidence is against the Veteran's entitlement to an initial disability rating in excess of 50 percent for an anxiety disorder. The Board has considered the Veteran's assertions that his anxiety disorder warrants a higher initial rating. The Board has considered the statements of the Veteran as to the extent of his anxiety disorder over the entire course of this appeal. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular disability rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). While he is competent to report that his symptoms are worse, the training and experience of medical personnel makes the medical findings found in treatment notes and examinations more probative as to the extent of the disability. See Cromley v. Brown, 7 Vet. App. 376, 379 (1995). Consideration has been given to assigning a staged rating for this claim; however, at no time during the time period in question has the Veteran's anxiety symptoms warranted the assignment of a rating higher than what has been herein affirmed. See Fenderson, 12 Vet. App. at 126. In conclusion, the Board finds that the criteria for an initial disability rating in excess of 50 percent for an anxiety disorder have not been met. Where, as here, the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, the Veteran's anxiety disorder does not warrant referral for extra-schedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. In this case, the Veteran has not expressly raised the matter of entitlement to an extra-schedular rating for his service-connected anxiety disorder. The Veteran's contentions have been limited to those discussed above, i.e., essentially that his disability is more severe than reflected by the currently assigned ratings. See Brannon v. West, 12 Vet. App. 32 (1998) (while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant). In this case, there has been no showing that the Veteran's disability picture for his anxiety disorder could not be contemplated adequately by the applicable schedular rating criteria discussed above. Those criteria provide for higher ratings in this case, but as has been explained thoroughly herein, the currently assigned ratings adequately describe the severity of the Veteran's symptoms. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's anxiety disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Referral for consideration of the assignment of a disability rating on an extra-schedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also 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). ORDER The appeal concerning the claim of entitlement to service connection for PTSD is dismissed. The appeal concerning the claim of entitlement to service connection for infection is dismissed. Entitlement to an initial disability rating in excess of 50 percent for an anxiety disorder is denied. REMAND Unfortunately, a remand is required for the remaining issue in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a) 5103A (West 2002 & Supp. 2010); 38 C.F.R. § 3.159(c) (2010). The Veteran seeks service connection for atrial fibrillation. In written statements (received in November 2005, December 2006, January 2008, July 2009, July 2010 and August 2010) the Veteran maintains that his heart problem began while in Vietnam with a hospital visit to treat some bacterial infection. He said that he had a fever of 104 or 105 degrees for four or five days and that he told his Army doctor over and over that his heart had started doing "funny things." However, he said that the doctor did not believe him and did not run any tests on his heart. In written statements received in February 2010 and March 2010 the Veteran also contended that his service-connected anxiety disorder did not cause his atrial fibrillation but that his atrial fibrillation worsened when he had panic attacks brought on by his service-connected anxiety disorder. In his November 2005 Notice of Disagreement, the Veteran stated that his service-connected anxiety disorder made his atrial fibrillation worse. Service personnel records show that the Veteran was a light vehicle driver in service and was stationed in the Republic of Vietnam from August 1970 to June 1971. An October 1969 service treatment record shows that the Veteran was seen for nervousness nearly a year before he was sent to Vietnam. He told the examiner that he got palpitations and "shaking in his boots" when he got nervous. The diagnostic impression was of anxiety. There is no indication of any cardiac examination. Other service treatment records do not show any hospitalization with a high fever while in Vietnam. A July 1971 discharge examination reveals no cardiac abnormalities. Post-service, private treatment records dated from May 1978 to January 2004 show arrhythmia by history in 1978. The Veteran was shown to have palpitations in 1983 and 1984. In 1985 he was diagnosed with atrial fibrillation and paroxysmal atrial fibrillation. Private medical records of Dr. W.E.K. noted that the Veteran had occasional palpitations in February 1987, December 1993, April 1997, April 1998, December 2001, and took medication for such. In October 2002, the Veteran was seen in the emergency room of Providence Hospital for irregular heart beat and was diagnosed with paroxysmal atrial fibrillation with rapid ventricular response. A January 2004 private medical record of Dr. W.E.K. noted that a cardiologist had prescribed Toprol XL daily to the Veteran's drug regimen and that this had helped control any palpitations. A February 2004 statement from Dr. W.E.K. noted that the Veteran had a current diagnosis of atrial fibrillation. In a May 2004 written statement, the Veteran claimed that his heart palpitates when he panics. He said this began in service when he started an anxiety state with his "heart running away" and continued to the present when he had heart palpitations after he panics when worrying about his youngest son. In the July 2005 VA mental examination, it was noted that the Veteran reported he began experiencing problems with an accelerated heart rate while he was still in service. The VA psychologist referred the question of whether the Veteran's heart arrhythmia was associated with his anxiety to another medical provider. In a subsequent July 2005 VA medical opinion, a VA physician noted an impression of paroxysmal atrial fibrillation and opined that this was not caused by or a result of anxiety. However, this VA examiner provided no rationale for his medical opinion and his review of the claims file neglected to mention that the Veteran's claimed heart palpitations were documented as a complaint in conjunction with his anxiety complaints in at least one service treatment record. In a January 2008 written statement the Veteran claimed that his heart "is pounding out of me and skipping around" when he leaves home for work at 4:30 a.m. when it is still dark outside. In the July 2008 VA mental examination it was noted that the Veteran's primary care provider had referred him to a cardiologist for atrial fibrillation. It was also noted that the Veteran took Tambocor and Toprol and that he had two private hospitalizations for atrial fibrillation in 1985 and 2002. The Veteran told the examiner during this mental examination that he had daily bouts of atrial fibrillation. The examiner suggested in her report of examination that the Veteran's atrial fibrillation might have been consistent with his history of psychosomatic complaints. The Veteran underwent a VA examination in February 2010. As a result of the examination there was no diagnosis of current atrial fibrillation or of ischemic coronary artery disease. However, the VA physician's assistant who acted as examiner did not have access to the claims file for this examination. While she noted that the Veteran "actually considers that his atrial fibrillation was at the time of Military service," she never noted in her report that at least one service treatment record documents that the Veteran had complained of heart palpitations at the same time he complained of nervousness or anxiety while in service. In his written statement of November 2010 and in his May 2011 Board testimony, the Veteran maintains that in spite of the diagnosis of the February 2010 VA examiner he still has atrial fibrillation and takes medication for it. The July 2005 and February 2010 VA examinations are clearly inadequate regarding whether or not the Veteran should be service-connected for atrial fibrillation, to include as secondary to his service-connected anxiety disorder. The February 2010 VA examiner did not have access to the claims file. The July 2005 VA examiner provided no rationale for his conclusion atrial fibrillation was not secondary to the anxiety disorder and never noted the Veteran's complaints in service of heart palpitations. The Board notes that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). VA's duty to assist the Veteran includes obtaining a thorough and contemporaneous evaluation where necessary to reach a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). Because of the inadequacy of these two VA examinations, the Board believes that on remand the RO/AMC should schedule the Veteran for a VA examination to determine if he currently has atrial fibrillation and, if so, whether such a disorder was caused by or aggravated by his service-connected anxiety disorder or is otherwise related to service. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall schedule the Veteran for an appropriate VA examination to assess the nature and etiology of his claimed atrial fibrillation. The entire claims file and a copy of this Remand must be reviewed by the examiner in conjunction with conducting the examination. All necessary tests and studies should be performed, and all findings must be reported in detail. The examiner is requested to provide an opinion as to whether the Veteran currently has atrial fibrillation and, if so, the etiology of this disorder, to include whether it is at least as likely as not (50 percent probability or greater) that any such disability found on examination was caused by or aggravated by his service-connected anxiety disorder or is otherwise related to the Veteran's period of active service. A complete rationale for any opinion expressed should be provided in a legible report. If the examiner concludes that an opinion cannot be offered without resort to speculation, it should be indicated and he or she should explain why an opinion cannot be reached. 2. When the development requested has been completed, the remaining issue on appeal should again be adjudicated by the RO/AMC. If the benefit sought is not granted the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs