Citation Nr: 1303113 Decision Date: 01/30/13 Archive Date: 02/05/13 DOCKET NO. 07-24 172A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for chronic anxiety prior to February 9, 2011. 2. Entitlement to a disability rating in excess of 70 percent for chronic anxiety from February 9, 2011 to the present. 3. Entitlement to a compensable disability rating for hemorrhoids. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1976 to January 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which increased the evaluation for the Veteran's service-connected migraine headaches to 10 percent effective July 20, 2005; continued a 50 percent evaluation for chronic anxiety, a 10 percent evaluation for gastroesophageal reflux disease (GERD) with a history of gastritis, a noncompensable evaluation for hemorrhoids, and a noncompensable evaluation for residuals of a left wrist injury and left trigger finger; and denied entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In November 2006, the Veteran submitted a notice of disagreement (NOD) with the denial of TDIU and continued evaluations for chronic anxiety and hemorrhoids. He subsequently perfected his appeal in August 2007. His case is currently under the jurisdiction of the VA RO in Indianapolis, Indiana. In January 2011, the Board remanded the Veteran's claims of entitlement to increased ratings for chronic anxiety and hemorrhoids and TDIU to the Appeals Management Center (AMC) for further evidentiary development, including providing the Veteran with additional notice, obtaining outstanding VA treatment records and Social Security Administration (SSA) records, and scheduling the Veteran for new VA examinations. The Board is obligated by law to ensure that the AMC complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the AMC sent the Veteran a letter with additional notice in January 2011. Additionally, the AMC obtained updated treatment records from the Indianapolis VA Medical Center and updated records from SSA. Finally, the Veteran was afforded new VA general medical and mental disorders examinations in February 2011. Accordingly, all remand instructions issued by the Board have been complied with and these matters are once again before the Board. In September 2011, the AMC increased the Veteran's disability rating for chronic anxiety to 70 percent, effective February 9, 2011. Because the AMC did not assign the maximum disability rating possible, the appeal for a higher evaluation remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed an NOD as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Since the Veteran perfected his appeal from the June 2006 continuance of the 50 percent disability rating for chronic anxiety, the Board will address whether he was entitled to a disability rating higher than 50 percent prior to February 9, 2011, and whether he is entitled to a disability rating higher than 70 percent from February 9, 2011, to the present. Therefore, the issue on appeal has been rephrased as shown above. The Veteran is not prejudiced by such recharacterization of the issue. An October 2011 statement from the Veteran indicated that he believed that his service-connected migraine headaches and GERD have worsened and that he has a bilateral ankle disability that was aggravated by his service-connected GERD. Thus, issues of entitlement to increased ratings for migraine headaches and GERD and whether new and material evidence has been received sufficient to reopen the previously denied claims of entitlement to service connection for right and left ankle disabilities have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's service-connected chronic anxiety is manifested by occupational and social impairment with deficiencies in most areas due to symptoms of anxiety, depression, nightmares, paranoia, sleep impairment, neglect of personal hygiene, and non-persistent auditory, visual, and olfactory hallucinations, with no evidence of total occupational and social impairment, persistent delusions or hallucinations, or persistent danger of hurting himself or others. 2. The Veteran's service-connected hemorrhoids are manifested by no more than moderate symptoms, including small internal hemorrhoids, annual or less frequent recurrences, occasional rectal bleeding, with no thrombosis, excessive redundant tissue, persistent bleeding, or fissures. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for the assignment of a disability rating of 70 percent, but no higher, for chronic anxiety have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). 2. The criteria for a compensable disability rating for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.114, Diagnostic Code 7336 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Prior to the Board's adjudication of the Veteran's claims, a letter dated in January 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio at 187. Additionally, the January 2011 letter informed the Veteran of how VA determines the appropriate disability rating or effective date to be assigned when a claim is granted, consistent with the holding in Dingess/Hartman v. Nicholson. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, VA treatment records and examination reports, and SSA records are in the file. The Veteran has not identified any additional private treatment records that he believes are relevant to his claims or that he wishes for VA to obtain. Thus, the Board finds that VA has satisfied its duty to obtain all available records. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO and AMC provided the Veteran with VA examinations for his chronic anxiety in May 2006, July 2007, and February 2011, and for his hemorrhoids in February 2006 and February 2011. The examiners reviewed the claims file and/or took a thorough history from the Veteran and provided a thorough physical examination, including all appropriate testing. Thus, the Board finds that the examinations of record are adequate for determining the disability rating for the Veteran's service-connected chronic anxiety and hemorrhoids. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, there is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected disabilities on appeal since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. Thus, the Board finds that a new VA examination is not necessary at this time for either chronic anxiety or hemorrhoids. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Chronic Anxiety The Veteran's service-connected chronic anxiety has been evaluated as 50 percent disabling prior to February 9, 2011, and 70 percent disabling from February 9, 2011, to the present under Diagnostic Code 9400. He seeks higher ratings. Under Diagnostic Code 9400, the General Rating Formula for Mental Disorders is used. The General Rating Formula provides that a 50 percent rating is assigned for 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 for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Finally, a 100 percent rating is assigned for 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. See 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). Although the Veteran's chronic anxiety is rated under the General Rating Formula, the use of the term "such as" in 38 C.F.R. § 4.130 indicates that the listed symptoms are not intended to constitute an exhaustive list. Rather, the symptoms listed under the General Rating Formula for Mental Disorders are to serve as examples of the type and severity of symptoms or their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the symptoms to be considered when rating a veteran's anxiety disorder are not limited to those listed in 38 C.F.R. § 4.130. Instead, VA shall consider all symptoms of a veteran's anxiety disorder that affect his level of occupational and social impairment, including, if applicable, those identified in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) 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 is defined as 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). A GAF score of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning "pretty well," with some meaningful interpersonal relationships. Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). As referenced above, the Veteran was first examined in conjunction with his present anxiety claim in May 2006. At that time, he complained of anxiety, worry, decreased sleep, nightmares two to three times per week, confusion, episodes of rage, an increased appetite, weight gain, decreased energy, anhedonia, poor concentration, claustrophobia, and panic attacks two to three times per month. The Veteran also reported experiencing depression, feelings of helplessness and hopelessness, and passive suicidal ideation. However, he denied suicidal intent, current homicidal ideation, auditory or visual hallucinations, and paranoia. The Veteran indicated that he was married to his third wife, but that the relationship had some conflict due to his unemployment, and that he had a good relationship with two of his children, but no relationship with another child since infancy. The examiner observed that the Veteran was fairly groomed and exhibited very mild psychomotor agitation, fair eye contact, anxious mood, full affect, and fair judgment and insight. She diagnosed the Veteran with generalized anxiety disorder, depressive disorder not otherwise specified, and a history of polysubstance abuse and assigned him a GAF score of 55 for generalized anxiety disorder only. She concluded that his psychiatric symptoms resulted in a decrease in both social and occupational functioning. The Veteran was next examined for his chronic anxiety in July 2007. At that time, he complained of anxiety that prevented him from going places and doing things, episodes of rage, mood variations, nervousness and anger around other people, infrequent auditory, visual, and olfactory hallucinations, frequent awakening due to nightmares, and homicidal thoughts. He denied obsessive or ritualistic behavior, panic attacks, and suicidal thoughts. The examiner observed that the Veteran had disheveled clothes, an inability to maintain minimum personal hygiene, lethargic and tense psychomotor activity, impoverished speech, an indifferent attitude, constricted affect, fair impulse control, mildly impaired remote and immediate memory, and an anxious mood. He diagnosed the Veteran with generalized anxiety disorder and psychosis NOS and assigned him a GAF score of 53. He concluded that the Veteran's psychiatric symptoms did not result in total social and occupational impairment, but did result in deficiencies in family relations, work, and mood. The examiner further opined that the Veteran's current diagnosis of psychosis NOS was a progression of his previously diagnosed generalized anxiety disorder. The Veteran was most recently examined in February 2011. At that time, he reported intense anger, anxiety, depression, nightly nightmares, and auditory, visual, and olfactory hallucinations that were not persistent. He indicated that he engaged in some obsessive or ritualistic behaviors such as avoidance of people due to germs, but only showered monthly or bimonthly. He endorsed homicidal and suicidal thoughts without intent and denied panic attacks. The examiner observed that the Veteran wore disheveled clothes and was lacking in personal hygiene, appeared to exaggerate his anxiety symptoms, lacked eye contact, and demonstrated spontaneous speech, mildly impaired immediate memory with normal remote and recent memory, and anxious, agitated, and expansive mood. She diagnosed him with a generalized anxiety disorder and psychotic disorder NOS and assigned him a GAF score of 55. She concluded that the Veteran's psychiatric symptoms did not result in total social and occupational impairment, but did result in deficiencies in thinking, family relations, work, and mood. In addition to the VA examination reports, the medical evidence of record includes VA treatment records which are generally consistent with the VA examination reports. VA treatment records reflect the same complaints noted in the VA examination reports and include GAF scores ranging from 50 to 65. Significantly, VA treatment records dated as early as July 2006 note the Veteran's paranoia and hallucinations. Additionally, SSA records indicate that the Veteran did not like to socialize but could do so if required and that he did not feel like he would be able to work in a job that required him to be around other people. The claims file also includes lay statements from the Veteran describing his psychiatric symptoms. His statements are consistent with the medical evidence of record. With resolution of reasonable doubt in the favor of the Veteran, the Board finds that the Veteran's generalized anxiety disorder has resulted in occupational and social impairment with deficiencies in most areas for the entire period on appeal. Specifically, the Veteran has exhibited anxiety, depression, nightmares, impaired sleep, impaired impulse control, neglect of personal appearance and hygiene, auditory, visual, and olfactory hallucinations, and social isolation which have resulted in few or no relationships other than with his wife and two of his children. Additionally, his GAF scores were rated at 50-65, indicating mild to moderate to serious symptoms or mild to moderate to serious difficulty in social, occupational, or school functioning. See DSM-IV at 44-47. This level of severity equates to the symptoms set forth in the criteria for a 70 percent rating. Accordingly, the Board finds that his symptoms more closely approximate a 70 percent rating for PTSD during the entire appeal period. However, although a higher rating is warranted, the evidence of record does not reflect symptomatology of chronic anxiety that would meet the criteria for a rating in excess of 70 percent for any period of time during the pendency of this claim. While the evidence of record demonstrates occupational and social impairment with deficiencies in most areas, it does not demonstrate total occupational and social impairment. Specifically, the Veteran has reported maintaining his marriage and good relationships with at least two of his children. Additionally, while the Veteran has been noted to be disheveled in appearance and lacking in personal hygiene, there is no evidence of gross impairment in thought processes or communication, persistent hallucinations or delusions, persistent danger of hurting himself or others, grossly inappropriate behavior disorientation to time or place, or memory loss for names of close relatives or own name. In addition, although the Veteran experiences hallucinations and passive suicidal and homicidal ideation, these hallucinations are not persistent and he has no intent or plan to harm himself or others. As such, a higher rating of 100 percent is not warranted. Additionally, the Board notes that there is no indication in the evidence of record that the Veteran's psychiatric symptomatology warranted other than the currently assigned 70 percent disability rating throughout the appeal period. As such, assignment of staged ratings is not warranted. See Hart, supra. For all the foregoing reasons, the Board finds that a rating of 70 percent for chronic anxiety is appropriate for the entire period of the appeal. In reaching this conclusion, the Board has applied the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Hemorrhoids The Veteran's service-connected hemorrhoids have been evaluated as noncompensably disabling under Diagnostic Code 7336. He seeks a higher rating. Under Diagnostic Code 7336, a noncompensable evaluation is assigned for internal or external hemorrhoids that are mild or moderate. A 10 percent evaluation is assigned for internal or external hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrence. A 20 percent evaluation is assigned for internal or external hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. See 38 C.F.R. § 4.114, Diagnostic Code 7336 (2012). As referenced above, the Veteran underwent VA general medical examinations that addressed his hemorrhoids in February 2006 and February 2011. At the time of the February 2006 VA examination, the Veteran reported a 20 year history of hemorrhoids that come and go. He further indicated that he was not currently seeking treatment for his hemorrhoids. The examiner did not provide any further details on the Veteran's hemorrhoids. The Veteran was again examined in February 2011, at which time he complained of stable hemorrhoids occurring once or less per year with occasional bleeding and no history of hospitalization, surgery, or thrombosis. The Veteran reported experiencing anal itching, burning, diarrhea, difficulty passing stool, and pain, but no tenesmus, swelling, fecal incontinence, or perianal discharge. The examiner noted that the Veteran had small internal and irreducible hemorrhoids with no evidence of rectal or other prolapse, thrombosis, bleeding, fissures, excessive redundant tissue, anorectal fistula, anal or rectal stricture, or sphincter impairment. She concluded that his hemorrhoids had no effect on his usual daily activities. In addition to the VA examinations, the medical evidence of record also includes VA treatment records that reference the Veteran's hemorrhoids. Notably, an October 2006 colonoscopy report indicated that the Veteran had internal non-bleeding hemorrhoids and external non-thrombosed hemorrhoids. A February 2007 VA treatment record noted rectal bleeding from time to time and an August 2010 VA treatment record noted a single episode of bright red blood in the Veteran's stool. These treatment records are consistent with the VA examinations of record. With regard to the Veteran's service-connected hemorrhoids, the medical evidence of record does not establish that the disability warrants a compensable disability rating. None of the medical evidence of record shows evidence of hemorrhoids that are more than mild or moderate. Specifically, there is no evidence to show the Veteran experiences hemorrhoids that are large or thrombotic, with excessive redundant tissue, or evidencing frequent recurrence. Rather, the evidence indicates that the Veteran's hemorrhoids are small, non-thrombotic, and occurring only occasionally. Although the February 2011 VA examiner noted that the Veteran's small hemorrhoids were irreducible, this symptom alone is not sufficient to warrant a compensable rating. Rather, the Veteran's hemorrhoids more closely approximate the rating criteria for a zero percent evaluation. There is also no evidence of persistent bleeding or fissures. Therefore, a compensable rating cannot be assigned under Diagnostic Code 7336. Additionally, there is no indication that the Veteran's service-connected hemorrhoids warrant an increased rating under any other diagnostic code relating to the digestive system. The Veteran is specifically service connected for hemorrhoids. The claims folder contains no medical evidence indicating that the Veteran's hemorrhoids have resulted in prolapse of the rectum, impairment of sphincter control, or other conditions. The examinations of record show normal sphincter control and no rectal prolapse or fecal incontinence or leakage. Thus, an increased rating cannot be assigned for hemorrhoids under Diagnostic Codes 7332-7335. See 38 C.F.R. § 4.114, Diagnostic Codes 7332-7335 (2012). Further, the Board notes that there is no indication in the medical evidence of record that the Veteran's hemorrhoids warranted other than the currently assigned noncompensable disability rating throughout the appeal period. As such, there is no basis for the assignment of staged ratings in this matter. See Hart, supra. Accordingly, the Veteran's claim of entitlement to a compensable disability rating for hemorrhoids must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Extraschedular Consideration The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With regard to the Veteran's service-connected chronic anxiety, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned 70 percent disability rating contemplate his symptoms, including anxiety, depression, impaired impulse control, and neglect of personal appearance and hygiene. The Board must consider any additional psychiatric symptoms that the Veteran exhibits, even if they are not specifically identified in the rating criteria. Thus, the Board finds that the Veteran's disability picture is adequately contemplated by the rating schedule. See Mauerhan, supra. As such, the threshold issue under Thun is not met for the Veteran's service-connected chronic anxiety and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. With regard to the Veteran's service-connected hemorrhoids, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned noncompensable disability rating contemplate his symptoms, including hemorrhoids with mild to moderate symptoms, including pain and occasional rectal bleeding. Thus, the Board finds that the Veteran's disability picture is adequately contemplated by the rating schedule. As such, the threshold issue under Thun is not met for the Veteran's hemorrhoids and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that either of the Veteran's service-connected disabilities discussed herein presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to a disability rating of 70 percent, but not higher, for chronic anxiety is granted for the entire appeal period, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a compensable disability rating for hemorrhoids is denied. REMAND With regard to the Veteran's claim for TDIU, the Board is cognizant of the fact that the Veteran's claim has been in adjudicative status since 2005, and that it has been remanded in the past. Consequently, the Board wishes to assure the Veteran that it would not be remanding this claim again unless it was essential for a full and fair adjudication. The Veteran was afforded an examination to address his employability to February 2011. At that time, the examiner addressed each of the Veteran's service-connected disabilities and opined on its effect on his employability. Specifically with regard to the Veteran's service-connected migraine headaches, the examiner noted that the Veteran experienced prostrating attacks lasting one to days on a weekly basis. However, she concluded that his migraine headaches only had a mild effect on his ability to engage in employment. This conclusion seems to be contradicted by her finding that he experienced disabling headaches every one to two out of seven days. In light of this discrepancy, the Board finds that the examiner's opinion on the Veteran's employability is inadequate to decide the TDIU claim. See Barr, supra. On remand, the examiner must explain this apparent discrepancy. As was explained in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), the Board may consider only independent medical evidence to support its findings. The Court went on to say that, if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. See Colvin at 175. For the reasons described above, the Veteran's claim of entitlement to TDIU must be remanded for an addendum opinion. Accordingly, the case is REMANDED for the following actions: 1. Return the claims file to the February 2011 VA examiner to clarify her opinion. Specifically, the examiner should explain her conclusion that weekly prostrating headaches, lasting one to two days, have only a mild effect on the Veteran's ability to maintain employment. A complete rationale should be provided for any opinion offered. If the February 2011 examiner is unavailable, schedule the Veteran for a VA examination to determine the effect of his service-connected disabilities on his employability. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination. That such a review took place must be noted in the examination report. The examiner should opine as to whether the Veteran is unable to secure or maintain substantially gainful employment solely as a result of his service-connected disabilities. A complete rationale should be provided for any opinion offered. 2. After completing the above actions and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim of entitlement to TDIU should be readjudicated. If the claims remains denied, a supplemental statement of the case should be provided to the Veteran and his representative, and after they have had an adequate opportunity to respond, the case should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs