Citation Nr: 1301534 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 09-33 558 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an initial disability rating in excess of 10 percent for the service-connected adjustment disorder with mixed anxiety and depression. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L.B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from December 1967 to July 1969. This case is before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In that decision, the RO granted entitlement to service connection for adjustment disorder with mixed Anxiety and Depression and assigned an initial noncompensable disability rating, effective from September 26, 2006. The rating decision also denied service connection for PTSD. The Veteran's Notice of Disagreement with that decision was received at the RO in August 2008. In the NOD, the Veteran specifically disagreed with the initial noncompensable rating assigned for the service-connected adjustment disorder, and did not disagree with any other aspect of the August 2007 rating decision. In an August 2009 rating decision, the RO increased the initial noncompensable disability rating for the service-connected adjustment disorder with mixed anxiety and depression from to 10 percent disabling, effective from September 26, 2006, the effective date of service connection. As this award did not represent a complete grant of benefits sought on appeal with respect to that issue, the appeal continued, and the RO therefore issued a Statement of the Case (SOC) in August 2009. The Veteran perfected his appeal with the submission of a timely substantive appeal (VA Form 9), which was received at the RO in September 2009. The Veteran indicated that he did not wish to be scheduled for a Board hearing. Finally, it is noted that a TDIU is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2012) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case the Veteran is employed. Inasmuch as there is no evidence of unemployability, TDIU is not raised by the record. FINDINGS OF FACT 1. Since the effective date of service connection, the Veteran's service-connected adjustment disorder with mixed anxiety and depression has been shown to produce an overall disability picture that more nearly approximates 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 and anxiety, with some irritability, nightmares, intrusive thoughts, sleep disturbance, and fair concentration and memory. 2. The medical and lay evidence of record establishes that the Veteran's adjustment disorder with mixed anxiety and depression has never been shown to produce an overall disability picture that more nearly approximates occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for the assignment of an initial disability rating of 30 percent, but no higher, for the service-connected adjustment disorder with mixed anxiety and depression have been met during the entire period covered by this appeal. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.130 including Diagnostic Code 9440 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Here, the Veteran filed his claim of service connection for depression in September 2006. In December 2006, the RO issued an initial duty-to-assist letter to the Veteran, followed up with an amended duty-to-assist letter four days later, that provided the Veteran with notice of all five elements of a service connection claim. Specifically, the Veteran was notified about how to substantiate a claim of service connection, what evidence VA would obtain on behalf of the Veteran and what evidence the Veteran should provide; notice of how VA determines the disability rating and effective date once service connection has been established. In response, the Veteran indicated in December 2006 that he had no other evidence to submit at that time. In an August 2007 rating decision, service connection for adjustment disorder with mixed anxiety and depression was granted and an initial noncompensable evaluation was assigned effective September 26, 2006. The Veteran disagreed with that determination, and appealed the initial noncompensable percent rating assigned for the service-connected adjustment disorder with mixed anxiety and depression. With regard to this increased rating claim, here, the Veteran is challenging the initial rating assigned following the grant of service connection for the psychiatric disorder. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Moreover, in a August 2009 rating decision, the 0 percent rating for the service-connected adjustment disorder with mixed anxiety and depression was increased to 10 percent, effective from September 26, 2006, the effective date of service connection. As the increase from 0 percent to 10 percent is not a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). With regard to VA's duty to assist the Veteran in the development of his claim, the RO obtained service treatment records, afforded the Veteran a physical examination, and afforded the Veteran the opportunity to give testimony before the Board. The medical examination report of July 2007 is adequate as it is based on a review of the history, a physical examination, and as information was provided that is sufficient to allow the Board to render an informed determination. All known and available records relevant to the service-connected adjustment disorder with depressed mood issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. A review of the Veteran's Virtual VA Folder reflects that no additional records have been added to the record which have not been reviewed. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. II. Increased Rating - Psychiatric disorder The Veteran seeks an initial rating in excess of 10 percent for the service-connected adjustment disorder with mixed anxiety and depression. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations should 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 all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. In cases such as this, where the Veteran appeals the initial rating assigned for a service-connected disability, consideration must be given to "staged" ratings, i.e., disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). It is also appropriate to consider whether separate ratings should be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings Hart v. Mansfield, 21 Vet. App. 505 (2007). 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 a rating 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. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126. Age may not be considered as a factor in evaluating a service-connected disability. 38 C.F.R. § 4.19. Diagnostic Code 9440 governs ratings for chronic adjustment disorder, based on the regulations set forth in 38 C.F.R. § 4.126 and § 4.130, the General Rating Formula for Mental Disorders. (Generalized anxiety disorder is rated pursuant to Diagnostic Code 9400 and major depressive disorder is rated pursuant to Diagnostic Code 9434, for example). Regardless of which diagnostic code is used to rate the psychiatric disability, the outcome is the same because all mental disorders are rated pursuant to the Schedule for Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. Under Diagnostic Code 9440, for example, a 10 percent evaluation is warranted when the veteran exhibits 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; when symptoms are controlled by continuous medication. A 30 percent evaluation is assigned for 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). A 50 percent evaluation is warranted when the veteran exhibits 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. The next higher, 70 percent, evaluation is warranted for a mental disorder where the veteran exhibits 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); and inability to establish and maintain effective relationships. A 100 percent rating is warranted where the veteran exhibits 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 main criteria for a total disability rating for any disability rated in accordance with the VA General Rating Formula for Mental Disorders are total occupational and social impairment. Sellers v. Principi, 372 F.3d 1318, 1324 (Fed. Cir. 2004). The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Global Assessment of Functioning (GAF) scores, which indicate the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health, are also useful indicators of the severity of a mental disorder. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). GAF scores ranging between 61 to 70 indicate 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores between 51 to 60 indicate 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). GAF scores between 41 to 50 indicate 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). Scores between 31 to 40 indicate some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). The evidence for consideration consists of service medical records, a VA examination from July 2007; VA outpatient mental health records from March 2005 through July 2008, the Veteran's competent and credible statements regarding his observable symptoms, as well as a December 2006 lay statement from the Veteran's wife. This evidence when reviewed collectively, establishes that the Veteran's service-connected adjustment disorder with mixed anxiety and depression more nearly approximates the criteria associated with the 30 percent rating, but not higher. VA outpatient treatment records from March 2005 indicate that the Veteran presented to the ER on March 10, 2005 with a complaint of depression and nightmares about Vietnam. He reported that his PTSD had worsened in the past two years. This evidence establishes that the Veteran felt anxious and depressed to the point of needing immediate care. However, the records indicate that the Veteran had no cognitive impairment, no psychosis, no evidence of alcohol or substance abuse, no suicidal or homicidal ideation, no violent behavior, no agitation, no hostility and the record specifically noted that the Veteran's did not present as a high risk situation. On physical examination, the Veteran was mildly anxious. The diagnosis was PTSD, and the Veteran was discharged with instructions to return to the ER as needed. 10 mg of Chlordiazepoxide daily was prescribed for anxiety. At an April 2005 VA mental health consult, the Veteran reported intrusive thoughts of Vietnam, and indicated that he was less interested in things that he used to enjoy, got upset when things reminded him of his combat experiences in Vietnam, and had nightmares about Vietnam. That notwithstanding, the Veteran also indicated that he was not concerned about his anger and he felt he could trust people around him. Also, when asked if he had any trouble becoming startled by sounds or things that were not threatening, he replied that he did not. He reported sleeping only five hours per night. According to the assessment, the Veteran did not score positive for the PTSD screen, he did not experience direct combat, had some nightmares at times, appeared anxious at times, but feels that past medications have helped with that. The Veteran had a full-time job and a very supportive wife. The Veteran was not interested in individual therapy and did not have suicidal or homicidal ideation. In May 2005, the Veteran underwent a VA mental health consultation. The Veteran reported using a lot of sick time from work because of depression and anxiety. The Veteran admitted to social withdrawal, behavior changes, sleep disturbance and depression. The Veteran denied symptoms of: deterioration of hygiene, ability to parent, a change in eating habits, panic attacks, obsessive/compulsive behavior, psychosis, paranoia, and mania. The assessment report indicates that the Veteran's favorite hobby is gardening, and the Veteran described his typical day as doing yard work. He continued to work full time and remained to his current spouse for 16 years. On mental status examination, the Veteran was appropriately dressed, fully alert and cooperative. Thought content was coherent, but insight was impaired. Speech was normal in tone and rate and thought processes were goal directed. Judgment was intact, mood was euthymic and affect was appropriate. The Veteran was oriented to person, place, time and situation. Concentration and memory were fair. The Veteran reported no homicidal or suicidal ideation. He reported that his family and friends were supportive. The Veteran reported recurrent intrusive thoughts and intrusive recollections about the Vietnam war, particularly triggered by war movies and more recently the news about the War in Iraq. The Veteran indicated that he had anxiety and irritability that caused him problems at work, but also had a very understanding boss at work who gave him sick time off when he needed it. The Veteran reported intermittent nightmares. The Veteran reported that he served in combat in Vietnam. In a December 2006 statement, the Veteran's wife of 23 years reported that the Veteran had bad nightmares, jumped when the phone rang, and hated fireworks. She explained that the Veteran began having flashbacks of his experiences in Vietnam when the Iraq War started. The Veteran's wife also reported that the Veteran was depressed and had no energy. She reported that sometimes he would just lie in bed all day, and although the Veteran was taken medications that helped his depression, he was still not the same man that she married. At a VA examination in July 2007, the Veteran's current marriage was described as "good" without conflict. The Veteran denied any history of significant conflict with his family and described these relationships in very positive terms. The Veteran reported having several friends in the community and establishes positive relationships with them. The Veteran liked gardening, but indicated that he had less energy as a result of his prostate cancer and diabetes. The Veteran reportedly regularly attended high school basketball games, but also indicated that he had a reduction in interest in going grocery shopping with his wife because of a "nervous" feeling in those situations. The Veteran reported sadness and a continued struggle with regaining the level of interest necessary to pursue the hobbies and interests that he previously enjoyed prior to his prostate cancer surgery in 2005. On mental status examination, the Veteran was clean and appropriately dressed. Speech was unremarkable. Attitude toward the examiner was cooperative, friendly, and relaxed. Affect was normal, mood was happy. The Veteran was oriented to person, time and place. Thought process and content was unremarkable. There were no delusions, and the Veteran understood the outcome of his behavior. As to his "sleep impairment" the Veteran reported that he only gets 5 hours of sleep per night because he works the night shift from 10 pm until 6:30 am. He generally described his sleep in positive terms. When asked about nightmares, the Veteran reported that he had a nightmare once in a great while, but not nearly as much since he stopped watching tv news stories about Iraq. As with the previous assessments, the Veteran had appropriate behavior. He did not report panic attacks, hallucinations, obsessive or ritualistic behavior, homicidal or suicidal ideation. The Veteran's impulse control was described as good, and there were no reported episodes of violence. There were no angry outbursts even before starting mental health treatment. There were no problems with activities of daily living. Memory was normal. Psychological testing included the Beck Depression Inventory which revealed mild severity. The PLCM results were not consistent with a PTSD diagnosis. The Veteran remained fully employed with the same employer for 20 years, and used 4 weeks of sick leave over the prior year due to low energy starting with the onset of diabetes and prostate cancer. The Veteran reported that sometimes he did not have the energy to get out of bed. The Axis I diagnosis was adjustment disorder with mixed anxiety and depression (in remission). Current Global Assessment of Functioning (GAF) was 70. With regard to occupational impairment, when symptoms were present, the Veteran lost several weeks of work due to fatigue. With regard to social functioning, there was a marked decline in energy that resulted in loss of participation in meaningful activities (e.g., gardening); loss of interest in sex; recent onset of anxiety in crowded places/mild avoidance. The Veteran reported subjective distress with emotional labiality and occasional crying at small things. The examiner explained that the Veteran's history of subjective distress and decreased energy level was likely related to the psychological implications of his medical conditions (e.g., sexual dysfunction and urinary incontinence associated with his prostate cancer diagnosis). With regard to the effects of the Veteran's mental disorder on occupational and social functioning, the examiner specifically indicated that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to mental disorder signs and symptoms, but with generally satisfactory functioning (routine behavior, self-care, and conversation normal). The examiner concluded that the loss of sexual functioning, the stress of a major medical illness, and frequent urinary incontinence resulted in a significant loss of identity which subsequently led the Veteran to develop symptoms of depression. The subsequent reduction in involvement in hobbies and activities likely worked to further exacerbate his mood symptoms. At a July 2008 VA mental health assessment, the Veteran was provided with a list of problems and complaints that people sometimes have in response to stressful life experiences; and he was asked to respond as to how much he was bothered by each problem in the past month. The problems and the Veteran's responses are as follows: 1. Repeated disturbing memories, thoughts or images of the stressful experience form the past? "A little bit." 2. Repeated disturbing dreams of the stressful experience from the past?. "A little bit." 3. Suddenly acting or feeling as if the stressful experience from the past were happening again (as if you were reliving it)? "Not at all." 4. Feeling very upset when something reminded you of the stressful experience form the past? "Moderately." 5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the stressful experience from the past? "Moderately." 6. Avoiding thinking about or talking about the stressful experience from the past or avoiding having feelings related to it? "Not at all." 7. Avoiding activities or situations because they reminded you of the stressful experiences from the past? "Not at all." 8. Trouble remembering important parts of the stressful experience from the past? "A little bit." 9. Loss of interest in activities that you used to enjoy? "Not at all." 10. Feeling distant or cut off from other people? "Not at all." 11. Feeling emotionally numb or being unable to have loving feelings for those close to you? "Not at all." 12. Feeling as if your future somehow will be cut short? "Not at all." 13. Trouble falling or staying asleep? "A little bit." 14. Feeling irritable or having angry outbursts? "Not at all." 15. Having difficulty concentrating? "Not at all." 16. Being super alert or watchful or on guard? "A little bit." 17 Feeling jumpy or easily startled? "Not at all." The Veteran's suicide screen was negative. The examiner noted that the Veteran was already receiving medication for treatment, and did not desire any mental health clinic services at that time. In sum, the evidence, which has been relatively consistent throughout the period covered by this appeal, showing that the Veteran has some periods where he is more depressed and anxious than at other times. During the period covered by this appeal, the Veteran has reportedly experienced nightmares, flashbacks, irritability, depression, a lack of energy and a lack of desire to engage in his hobbies. Although the Veteran does not report panic attacks, the Veteran did indicate that he occasionally felt anxious and moderately upset with some physical reaction such as sweating or heart pounding for example, when something reminded him of the stressful experience from the past. From a functional standpoint, the Veteran could no longer garden, one of his favorite hobbies, because he lacked the energy necessary to accomplish this task. The examiner in 2007 attributed this lack of energy to both his physical ailments (prostate cancer and diabetes) as well as his depression. The Veteran also reportedly was not comfortable in some social settings, as he once had been. This was attributed to his anxiety. With regard to the effects of the Veteran's mental disorder on occupational and social functioning, the July 2007 VA examiner specifically indicated that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to mental disorder signs and symptoms, but with generally satisfactory functioning (routine behavior, self-care, and conversation normal). This description of the Veteran's disability of his occupational and social functioning falls squarely within the criteria for the assignment of a 30 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9440. The Veteran has a depressed mood and anxiety, with an occasional feeling of panic. He experiences occasional nightmares, and feels a bit suspicious with some exaggerated startle response at times. These symptoms and level of social and occupational dysfunction more nearly approximate the criteria for the assignment of the 30 percent rating. Although the Veteran's symptoms are chronic in nature, he does not experience all of them all of the time. He has reported that his symptoms come and go, and based on his responses to questions on mental health assessments and the VA examination report, the Veteran is clearly functioning satisfactorily, with only occasional periods of inability to perform occupational tasks. This is evidenced by the Veteran's report that he had to take 4 weeks of sick leave during a one year period due to his lack of energy, which is only partly attributed to his depression. Moreover, the Veteran's GAF score was listed as 70, which indicates 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Thus, the assignment of a Global Assessment of Functioning (GAF) of 70 also supports the assignment of a 30 percent rating. The Veteran's psychiatric symptoms do not, however, more nearly approximate those associated with the 50 percent rating criteria. A 50 percent rating is assigned when the veteran exhibits 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. The Veteran does not exhibit the types of symptoms associated with the 50 percent rating other than disturbances of motivation and mood. Moreover, the Veteran's disturbance of motivation and mood has been associated with "depressed mood and anxiety" associated with the 30 percent rating. While the Veteran does experience decreased motivation, part of that has been attributed to a lack of energy associated with the physical disabilities such as prostate cancer and diabetes. Moreover, that symptom, alone, does not support the assignment of a 50 percent rating. Furthermore, the Veteran appeared to every examination and mental health assessment properly dressed, acted appropriately at all times, and had no speech deficits. The Veteran reported some irritability at times, but specifically noted that he had never lost control and had no trouble with impulse control. The Veteran reported having good relationships with family and friends, and a good relationship with his boss at work. The Veteran was able to remain productive at work and he never reported any obsessive/compulsive behavior, psychosis, paranoia, mania, suicidal ideation, or anger. Moreover, there were no deficits with respect to his affect, speech, judgment, thinking or a memory impairment to the extent that he only retained highly learned material or forgot to complete tasks. The symptoms manifested, including depression, anxiety, occasional panic and nightmares, intrusive thoughts of Vietnam, some social withdrawal, behavior changes, sleep disturbance, impaired insight, fair concentration and memory, irritability and some lack of energy, ultimately result in occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. These symptoms do not support the assignment of a rating in excess of 30 percent as they do not indicate that the Veteran has occupational and social impairment with reduced reliability and productivity. The Veteran has positive social relationships and works full time without job complaints. The Veteran is considered credible and competent to report his symptoms as these are observable symptoms which do not require medical expertise to diagnose. The Board emphasizes that it has considered whether the symptomatology exhibited warrants a higher evaluation than 30 percent, without requiring that the evidence show the symptoms that are listed as examples under the criteria for a 50 percent, or higher, rating in the schedule of rating criteria. The Veteran's depression, nightmares, anxiety, intrusive thoughts of Vietnam, some social withdrawal, behavior changes, sleep disturbance, impaired insight, fair concentration and memory, irritability, lack of energy, and his physical reaction in response to recollections, with an assigned GAF score of 70, more nearly approximate occupational and social impairment with an occasional decrease in work efficiency ad intermittent periods of inability to perform occupational tasks. The symptoms reported by both the Veteran and his wife, which are found to be competent, credible, and probative, and the severity of those symptoms and signs have been considered and are found to warrant the assignment of a 30 percent rating, but no higher for the service-connected adjustment disorder with anxiety and depression. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The criteria for the assignment of this 30 percent rating, but not higher, have been met during the entire period covered by this appeal, as there are no distinct time periods where the Veteran's symptoms warrant different ratings. However, the preponderance of the evidence is against the assignment of any higher rating. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Finally, the Board has considered whether referral for consideration of an extraschedular rating is warranted. 38 C.F.R. § 3.321(b)(1) (2011); Thun v. Peake, 22 Vet. App. 111 (2008); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, there has been no showing that the service-connected adjustment disorder with anxiety and depression has rendered impracticable the application of the regular schedular standards. The regular schedular standards contemplate the symptomatology shown in this case as was shown above. The Veteran's signs and symptoms, including depression; anxiety; occasional panic; nightmares; intrusive thoughts; some social withdrawal; impaired insight; fair concentration and memory; irritability; and sleep disturbance, which result in an overall decrease in work efficiency and intermittent inability to perform occupational tasks, are contemplated within the schedular criteria. In essence, there is no evidence of an exceptional or unusual disability picture in this case which renders impracticable the application of the regular scheduler standards for rating mental disorders. The assignment of a 30 percent rating contemplates that there is commensurate industrial impairment. Therefore, referral for consideration for an extraschedular evaluation is not warranted here. 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER A 30 percent disability rating, but no higher, for the service-connected adjustment disorder with anxiety and depression is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs