Citation Nr: 1300338 Decision Date: 01/04/13 Archive Date: 01/11/13 DOCKET NO. 06-11 757 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to an initial evaluation in excess of 50 percent for anxiety disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran served on active duty from July 1967 to July 1970. This matter originates from a May 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, that granted service connection for anxiety disorder and assigned a 50 percent evaluation, effective July 16, 2003. The Veteran disagreed with the assigned rating and by decision dated in October 2010, the Board denied a higher initial rating. The Veteran appealed the October 2010 decision to the United States Court of Appeals for Veterans Claims (Court) and in a Memorandum Decision dated in March 2012, the Court set aside the October 2010 decision and remanded the matter for readjudication. The matter is once again before the Board. A review of the record shows that the Veteran had initiated an appeal (by filing a Notice of Disagreement in December 2008) of a December 2008 decision proposing to reduce the Veteran's 100 percent evaluation for lung cancer, status post pneumonectomy right lobe, to 0 percent. However, in July 2009, the RO issued a rating decision continuing the Veteran's 100 percent evaluation. As this represents a full grant of the benefits the Veteran sought with respect to this issue, the issue will not be further addressed. Also, in the Court's Memorandum Decision of March 2012, the Court reported that the evidence, namely a December 2005 report from Dr. Parenti, squarely raised the issue of unemployability which the Board should have adjudicated as a part of the increased rating claim and should do so on remand. However, a review of the record shows that the RO granted service connection for a total disability rating based on individual unemployability due to service connected disability in a September 2011 rating decision and provided the Veteran with notice of this decision that same month. As this represents a full grant of the benefits with respect to the issue of unemployability, the issue will not be further addressed. FINDING OF FACT The symptoms of the Veteran's anxiety disorder have throughout the appeal period most nearly approximated occupational and social impairment with deficiencies in most areas to include work, relationships, judgement, thinking, or mood. CONCLUSION OF LAW The criteria for a rating of 70 percent for anxiety disorder for the entire appeal period have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9413 (2012) REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to notify and assist Initially, the Board notes that, in November 2000, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002). To implement the provisions of the law, VA promulgated regulations published at 66 Fed. Reg. 45,620 (Aug. 29, 2001) (codified at 38 C.F.R. § 3.102, 3.156(a), 3.159, 3.326(a) (2012)). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Court's decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. In the present appeal, since the appellate issue (entitlement to assignment of a higher initial rating) is a downstream issue from that of service connection (see October 2004 VCAA letter), another VCAA notice is not required. VAOPGCPREC 8-2003. The Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 472 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service- connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman, supra. In the instant case, the Veteran was informed of the degree of disability and effective date elements in a March 2006 letter. The Board finds that all necessary assistance has been provided to the appellant and the RO has made reasonable and appropriate efforts to assist the appellant in obtaining the evidence necessary to substantiate his claim for a higher rating for his anxiety disorder. VA has obtained identified medical evidence and afforded the appellant VA examinations. To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Although the June 2009 VA examiner noted that he did not have the Veteran's claims file to review, only his electronic medical records, the Board finds that all of the VA examination reports on file contain sufficient findings with which to properly evaluate the appellant's service-connected anxiety disorder and are thus deemed adequate for rating purposes. See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). All of the examination reports are predicated on a physical examination and contain the findings necessary to evaluate the appellant's anxiety disorder under the applicable rating criteria. Also, in the Court's Memorandum Decision of March 2012, the Court relayed the appellant's argument that VA failed to fulfill its duty to assist by neglecting to seek or obtain records of his past employment. However, VA has obtained the Veteran's SSA records showing his work history and that he stopped working in 2003 due to a heart condition. VA also accepts as credible the Veteran's statements at the November 2003 VA examination that he had many jobs over the years most of which he denied being fired from, but rather that he usually got angry and left. In light of this evidence of record, the Board does not find that the Veteran is prejudiced in any way by not obtaining his actual employment records. See Bernard v. Brown, 4 Vet. App. 384 (1993). The appellant has not indicated that any additional pertinent evidence exists with respect to this claim, and there is no indication that any such evidence exists. Under these circumstances, the Board finds that VA has fulfilled its duty to notify and assist the appellant in the claim on appeal and that adjudication of the claim at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the appellant. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The appeal is now ready to be considered on the merits. II. Facts VA outpatient treatment records in June 2003 and July 2003 reflect diagnoses of alcohol dependence and PTSD and GAF scores of 45. In July 2003, the Veteran filed a claim for service connection for PTSD. A VA mental health progress note in July 2003 contains the Veteran's report of daily intrusive thoughts of Vietnam. He reported sleep difficulty, but denied nightmares. He also reported being irritable and anxious and said he felt trapped very easily. He said that he avoided crowds and reminders of war. He reported being distrustful of others and had difficulty relating to others. He said he had been divorced twice and had two grown children one of whom he had lived with, but that the living arrangement did not work out. He said he received treatment for substance abuse in the 1970s, and denied treatment for PTSD. At a VA examination in November 2003, the Veteran's reported symptoms were noted to be consistent with anxiety disorder. Such symptoms included chronic anxiety and worry, poor sleep with frequent midnight awakenings, and panic attacks described in the past as being "severe and disabling". He was also described as avoiding crowds and having a fear of closed in spaces and bridges. He was noted to have worked as a mechanic and held many jobs over the years, the longest of which lasted four years. He denied that he had been fired from most of these jobs, but said that he usually got angry and left. He said he was dismissed from his last job of two and a half years due to absenteeism and tardiness. He also said he has since collected unemployment and was living in a motel. On examination the Veteran was cooperative and had relatively poor eye contact. He was observed rubbing his leg nervously and his affect and mood were dysphoric. His thoughts were logical with no evidence of thought disorder. He reported occasional auditory hallucinations which the examiner noted did not appear clinically significant. The Veteran denied active suicidal ideation and his cognition was grossly intact. He had fair insight and judgment. He was given an impression of anxiety disorder not otherwise specified, with panic, generalized anxiety, and phobic symptoms. He was also diagnosed as having alcohol dependence, in full remission for seven months. He was assigned a global assessment of functioning (GAF) score of 55. In February 2004, the RO denied the Veteran's claim for service connection for PTSD. Also in February 2004, the RO received health records from the State of Connecticut showing that in 2003 the Veteran had been treated for depression, anxiety disorder and PTSD. He was treated at the Rocky Hill Home and Hospital and underwent a Mental Status Evaluation in July 2003 conducted by a psychologist. At the evaluation the Veteran reported that he had been married twice and his first marriage lasted 13 years. He said he had two children from his first marriage and was not on good speaking terms with them due to frequent arguments. He said he had lived with his second wife for 13 years prior to marrying her and that the marriage lasted approximately two years. He said the relationship failed due to his drinking. He said he had used valium in the 1970s to treat his anxiety and currently reported a depressed mood, guilt feelings, insomnia, weight gain, and history of suicidal ideation in the 1970s with no attempts. He reported panic attacks, anxiety in crowded places and paranoid feelings. Psychological testing revealed that the Veteran was experiencing a lot of emotional distress in general and had experienced a moderate level of depressive symptoms. On examination the Veteran was well-groomed and had a depressed mood. His attitude was cooperative and his affect was constricted. He had normal speech and was relaxed and calm. His judgment was impulsive and his insight was intact. His thought process was logical and organized. His functioning level was assessed to be between "51-60". In September 2004, the Veteran filed a claim for service connection for "severe anxiety, panic attacks & phoebic symptoms & depression." A VA mental health progress note in March 2005 shows that the Veteran had been attending weekly substance abuse/PTSD conflict resolution group meetings for three months. A June 2005 progress note notes that the Veteran tended to isolate and had a hard time leaving the house. He had no vegetative signs of depression. A September 2005 psychiatric nursing progress note shows that the Veteran had not come to the weekly support group since June 2005 and that his file was being closed administratively. On file is a December 2005 letter from the Veteran's private psychologist, R. Parenti MS/DAGS, who relayed the Veteran's report of auditory and visual hallucinations which he said would suggest some form of organic psychoses although he did not see a true thought disorder or significant neurological problem on testing. He said the Veteran also presented with a variety of very debilitating anxieties, phobias and panic attacks and reported that the Veteran was unable to function in a crowd. He went on to report that the Veteran flies into tower rages and tantrums at the least provocation. He opined that the Veteran was psychologically completely disabled and unable to even hold a menial job. The Veteran attended a VA psychiatric examination in July 2007 where he reported that he had previously been treated at a VA mental hygiene clinic in 2005, and had recently resumed treatment over the past month. The examiner reported that the Veteran's present clinical picture was quite consistent with the description provided in the earlier VA examination in 2003. He relayed the Veteran's report of mood disturbance manifested by chronic episodes of anxiety, as well as irritability. He reported that the Veteran still had trouble sitting still, thinking and planning. He also reported sleep disturbance and discomfort in large crowds. He said his prominent source of anxiety was his medical status, having suffered a heart attack in 2003 and had recently started drinking again. The examiner further reported that the Veteran essentially stopped working following his heart attack, but prior to that had experienced increased stress and unpleasant circumstances involving more difficult work standards. He noted that the Veteran was relatively socially isolated and reported that he had no close friends. He was noted to be living with his ex-wife whom he did not spend much time with, but did report enjoying good relationships with his two adult children. Findings revealed that the Veteran appeared mildly anxious and uncomfortable throughout the interview. There were no signs or symptoms of psychosis. His mood was mildly to moderately anxious with no homicidal or suicidal ideation. There was no evidence of behavioral or impulse control with the exception of chronic episodes of irritability such as road rage. The Veteran also acknowledged a chronic problem with alcohol. The examiner reported that the Veteran clearly suffered from an ongoing anxiety disorder manifested by chronic anxious feelings and tendencies toward hypervigilance, chronic difficulties in concentrating and planning, and episodes of irritability. He said he also continued to abuse alcohol with some periods of sobriety. The examiner said that functionally, the Veteran seemed to view himself as an old and ill man and seemed to have decided a life course entailing minimal stress. He explained that the Veteran spent much of his day in solitary activities, largely to avoid stress, anger and anxiety. He said his assigned GAF of 50 was consistent with his last examination and recent medical notes. The examiner said there was no evidence to suggest the Veteran's clinical or functional status had significantly deteriorated because of his psychiatric diagnoses of anxiety disorder NOS, episodic alcohol abuse and nicotine dependence. On file is a psychiatric consult report from a VA mental health clinic dated in July 2007. According to this report, the Veteran had a long history of anxiety and panic attacks as well as alcohol abuse which the Veteran said was a way of medicating his feelings of panic and anxiety. The Veteran reported that he had recently separated from his second wife and moved in with his first wife whom he was on friendly terms with. Findings in July 2007 revealed that the Veteran was alert and oriented times four. His mood was dysphoric and irritable. He denied suicidal or homicidal ideation. He had a moderate to severe level of anxiety with accompanying avoidance behavior. He also had decreased sleep and appetite. An August 2007 progress note contains similar findings, except that it notes that the Veteran's mood had improved. Similar findings are also noted in progress notes in October 2007, except that these notes state that the Veteran's mood was anxious. These notes also show that the Veteran's alcohol abuse continued unabated. In June 2009, the RO received records from the Social Security Administration showing that the Veteran had been awarded disability benefits in May 2004, effective in December 2003, for acute myocardial infarction and chronic ischemic heart disease with or without angina. These records include duplicate private treatment records in 2003 noting depression, anxiety and PTSD. Also in June 2009, the Veteran underwent a VA psychiatric examination. The examiner remarked that he did not have the Veteran's claims file to review, but did review his electronic medical records. He reported that the Veteran was last treated in 2007 at the Waterbury outpatient mental health treatment clinic and relayed the Veteran's report of chronic difficulties with anxiety and nervousness. He also relayed that the Veteran experienced panic attacks 2-3 times a week, although he indicated they were not as severe as they had been in the past as he had learned how to better control them. He went on to describe significant experiences of panic, particularly in crowded areas. He said the attacks were characterized by shortness of breath, palpitations, feelings of derealization and thoughts of dying. He also reported continuing difficulties with irritability brought on by intense experiences of anxiety. He reported sleep disturbances at night. The Veteran reported that he was not very happy, but denied being depressed. He denied using alcohol or cigarettes since his surgery in 2007 and reported no inappropriate behaviors. He said he last worked in 2003 as an auto mechanic and has been on disability since that time. The examiner remarked that based on the Veteran's description of medical issues and level of fatigue, it appeared that it would be quite difficult for him to return to his previous occupation considering his reported physical symptoms. He said the Veteran's level of anxiety would likely cause significant impact in his return to work as well. On examination the Veteran was casually, but neatly dressed. He was well groomed. His eye contact was variable, and he appeared highly anxious, restless, and uncomfortable throughout the interview. His mood was anxious and mildly dysphoric. He denied suicidal or homicidal ideation. His thought process was generally logical and goal-directed. He had fair insight and judgment. He was given an impression of anxiety disorder not otherwise specified and alcohol dependence in sustained full remission. He was assigned a GAF score of 50. The examiner summarized by stating that the Veteran presented with symptoms of an anxiety disorder, characterized by panic attacks, restlessness, social anxiety, irritability, and sleep disturbance, and his reported symptoms appeared quite similar to those noted in his prior examination. He said the Veteran had experienced significant medical problems which had impacted his ability to work, and he currently spends most of his time alone, attempting to avoid stressors. He said the Veteran's last surgery (in 2007) caused him to quit smoking and drinking and he reported feeling less comfortable without his use of alcohol on a regular basis. The examiner reported that the Veteran had not been involved in mental health treatment since 2007 and could benefit from a psychotropic medication evaluation for his significant symptoms of anxiety. VA outpatient records in May 2011 suggest that the Veteran resumed drinking alcohol in excess. III. Law and Analysis Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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 Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case as is this case or not. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability has not significantly changed and a uniform evaluation is warranted. The Veteran's anxiety disorder, not otherwise specified, is evaluated as 50 percent disabling under the pertinent criteria for rating mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9413. This rating contemplates 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. A 70 percent rating is assigned when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent schedular rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The GAF is a scale reflecting the psychological, social and occupational functioning under a hypothetical continuum of mental health - illness. See American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score between 41 and 50 is reflective of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment of social, occupational, or school functioning (no friends, unable to keep a job); a GAF between 51 and 60 is indicative of 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 coworkers). A GAF between 61 and 70 is indicative of some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. See DSM- IV at 46-47. In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the probative value of proffered evidence in the context of the record as a whole. See Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997). The probative value of medical evidence is based on numerous factors and determining the weight to be attached to such evidence is within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 461, 470-71 (1993). By comparing the pertinent medical evidence in the instant case to VA's criteria for rating mental disorders, the Board finds that the Veteran's anxiety disorder is more consistent with a 70 percent rating during the duration of the appeal. The examination reports and treatment records, along with the Veteran's statements, show that his predominant symptoms include sleep impairment, anxiety, irritability, panic symptoms, discomfort in crowds, restlessness and social isolation. As far as the criterion of near-continuous panic or depression affecting the ability to function independently, the Veteran's report of panic attacks dates back to the November 2003 VA examination at which time they were described as "severe and disabling". The Veteran was given an impression at that time of anxiety disorder, not otherwise specified, with panic symptoms. His private psychologist, Dr. Parenti, in December 2005 reported that the Veteran had a variety of very debilitating anxieties, phobias and panic attacks. At the VA examination in July 2007, the Veteran reported that he abused alcohol as a way of medicating his feelings of panic and anxiety. Also, the VA examiner in June 2009 remarked that the Veteran's anxiety disorder was characterized by panic attacks which the Veteran reported as occurring two to three times a week. The Veteran described the attacks as involving shortness of breath, palpitations, feelings of derealization and thoughts of dying. The frequency of these attacks in addition to the characterization of them in the medical records as severe and debilitating satisfies the criterion of near-continuous panic or depression affecting the ability to function independently. As far as the criterion of impaired impulse control (such as unprovoked irritability and periods of violence), the Veteran's irritability is clearly shown in his medical records. His reports of feeling irritable date back to a VA mental health progress note in July 2003. Also, Dr. Parenti reported in his December 2005 letter that the Veteran flies into tower rages and tantrums at the least provocation. The VA examiner in July 2007 reported that the Veteran's anxiety disorder was manifested by chronic episodes of irritability such as road rage. The Veteran reported to the VA examiner in June 2009 that he continued to have difficulty with irritability brought on by intense experiences of anxiety and the examiner reported that his anxiety disorder was characterized by irritability. Also, the Veteran has clearly shown difficulty in adapting to stressful circumstances (including work or a work-like setting). This is evident by the VA examiners' remarks in July 2007 and June 2009 that the Veteran spent much of his day in solitary activities, largely to avoid stress, anger and anxiety. The July 2007 examiner explained that functionally the Veteran seemed to view himself as an old and ill man and seemed to have decided a life course entailing minimal stress. The June 2009 examiner also reported that in addition to medical issues, the Veteran's level of anxiety would likely cause significant impact in his return to work. Additionally, the Veteran reported at the November 2003 VA examination that he had held many jobs over the years most of which he denied being fired from, but that he usually got angry and left. In terms of an inability to establish and maintain effective relationships, the fact that he spends most of his time alone is telling of his inability to establish and maintain effective relationships. Moreover, he has been divorced twice and reported that he has no close friends. His relationship with his two adult children has fluctuated between not being on good speaking terms with them due to frequent arguments (see Rocky Hill Home and Hospital Mental Status Evaluation of July 2003) to enjoying good relationships with them (see June 2009 VA examination report). At the time of the June 2009 VA examination, the Veteran was living with his ex-wife whom he said he did not spend much time with. It should be noted that with respect to the Veteran's reports of symptomatology outlined above, to the extent that he has been consistent in his reports, and such reports are consistent with the observations of trained professionals, the Board finds the Veteran's reports to be credible. The Veteran has predominantly been assigned a GAF score of 50 for his anxiety disorder, with a few exceptions to include a score of 55 in November 2003 and a "functioning level" assessment between 51 and 60 in February 2004. Although VA outpatient records in June 2003 and July 2003 reflect GAF scores of 45, the Veteran was not diagnosed at that time as having an anxiety disorder; rather, he was shown to have alcohol dependence and was diagnosed as having PTSD. In any event, as noted above, GAF scores ranging between 41 to 50 reflect 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 between 51 and 60 is indicative of 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 coworkers). The Veteran's scores are consistent with the July 2007 VA examiner's assessment that the Veteran had a moderate to severe level of anxiety with accompanying avoidance behavior and are consistent with a 70 percent rating. Although the Veteran has not been shown to satisfy all of the criteria for a 70 percent rating for the period under consideration, he is not required to. Rather, what is required is that the evidence shows that he suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Thus, for the foregoing reasons, the Board finds that the Veteran's service-connected psychiatric disability picture more closely approximates the criteria for a 70 percent rating for the pertinent period. Consideration of a total, 100 percent, schedular rating for the Veteran's PTSD has been considered from July 16, 2003. However, the Veteran's actual symptoms as described in the evidence above do not meet the criteria for a 100 percent rating. In this regard, the evidence does not show total occupational and social impairment or that the Veteran has any of the symptoms listed under the criteria for a 100 percent rating for total occupational and social impairment. Specifically, the evidence consistently shows that the Veteran does not have symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior or persistent danger of hurting self or others. While he did report at the November 2003 VA examination that he had occasional auditory hallucinations, the examiner noted that this did not appear clinically significant. Similarly, private psychologist Dr. Parenti in December 2005 relayed that the Veteran's report of auditory and visual hallucinations would suggest some form of organic psychosis or seizure disorder, but that he did not see a true thought disorder or significant neurological problem on testing. In terms of occupational impairment, the record shows that the Veteran stopped working in 2003 due to a cardiovascular condition and his last job was an auto mechanic. He was granted SSA benefits effective in December 2003 for acute myocardial infarction and chronic ischemic heart disease with or without angina. In noting that the Veteran stopped working following his heart attack in 2003, the July 2007 VA examiner reported that prior to that the Veteran experienced increased stress and unpleasant circumstances involving more difficult work standards. Later, the June 2009 VA examiner reported that it would be quite difficult for the Veteran to return to his previous occupation based on his description of medical issues and level of fatigue. He went on to opine that the Veteran's level of anxiety would likely cause significant impact in his return to work. While these opinions clearly show that the Veteran's anxiety disorder causes deficiencies in his work, they fall short of showing total occupational and social impairment due solely to his psychiatric disorder. Thus, even after considering the December 2005 opinion of Dr. Parenti who opined that the Veteran was psychologically completely disabled and unable to even hold a menial job, the Board does not find that the record as a whole, for the reasons above, more closely approximates total occupational and social impairment due to the Veteran's service connected anxiety disorder. See Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997); Guerrieri v. Brown, 4 Vet. App. 461, 470-71 (1993). Regarding relationships, while there is obvious impairment in the Veteran's occupational and social relationships, he was noted in June 2009 to be living with his ex-wife which the records show he moved in with in July 2007 at which time he reported being on friendly terms with. He also reported in June 2009 that he enjoyed good relationships with his two adult children. He was noted at all of the VA examinations to be generally oriented with no thought disorder and there is no indication that he is unable to perform activities of daily living, including maintaining personal hygiene, or has memory loss for names of close relatives, occupation or own name. In sum, the Veteran's service-connected anxiety disorder is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Such symptomatology warrants a 70 percent disability rating for the entire rating period. The Board finds that the criteria for the 100 percent rating are not established by his symptomatology, and it therefore cannot be said that the Veteran's disability picture more nearly approximates that contemplated for the 100 percent rating. As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F. 3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's PTSD are fully contemplated by the applicable rating criteria. The many symptoms listed in the criteria for a 70 percent rating are similar to those that the VA treatment records and examination reports indicated were experienced by the Veteran, and the Board has thus been able to compare the Veteran's psychiatric symptoms with those listed in the relevant criteria. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. Therefore, referral for consideration of an extraschedular rating for PTSD is not warranted. 38 C.F.R. § 3.321(b)(1). For the foregoing reasons, the preponderance of the evidence reflects that the Veteran's anxiety disorder more nearly approximate the criteria for a 70 percent schedular rating throughout the appeal period. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for a higher rating for anxiety disorder must therefore be granted to the extent indicated. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F. 3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to an initial evaluation of 70 percent for service connection anxiety disorder is granted. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs