Citation Nr: 1304989 Decision Date: 02/11/13 Archive Date: 02/21/13 DOCKET NO. 05-25 394 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for service-connected mixed anxiety-depressive disorder. 2. Entitlement to an initial compensable disability rating for service-connected right great toe sprain. 3. Entitlement to an initial disability rating in excess of 10 percent for service-connected right shoulder sprain. 4. Entitlement to service connection for a right wrist sprain. 5. Entitlement to service connection for a bilateral ankle condition. 6. Entitlement to service connection for a bilateral knee sprain. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant served on active duty from September 2000 to August 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In July 2008, the appellant was scheduled for a videoconference hearing before the Board. However, he failed to appear. In December 2009 and August 2011, the Board remanded the matter for additional development and due process concerns. For the reasons discussed below, the Board finds that there was substantial compliance with the mandates in regard to the issue of entitlement to an initial disability rating in excess of 30 percent for service-connected mixed anxiety-depressive disorder. See Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to an initial compensable disability rating for service-connected right great toe sprain, entitlement to an initial disability rating in excess of 10 percent for service-connected right shoulder sprain, entitlement to service connection for a right wrist sprain, entitlement to service connection for a bilateral ankle condition, and entitlement to service connection for a bilateral knee sprain are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Throughout the rating period on appeal, the appellant's mixed anxiety-depressive disorder was manifested by anxiety, mild short-term memory loss and difficulty developing and maintaining friendships, productive of occupational and social impairment comparable to no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for entitlement to an initial evaluation in excess of 30 percent for mixed anxiety-depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9400 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. 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 appellant 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 appellant). 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 claimant. 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, 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). I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). This appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for a psychiatric disorder. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of the claim, which is not abrogated by the granting of service connection. The duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. In a September 2011 letter, the agency of original jurisdiction (AOJ) requested that the appellant provide information regarding the health care providers who had treated him for each claimed condition. However, he did not respond to the letter. The letter was not returned as undeliverable and the appellant attended a scheduled VA examination in October 2011. VA's duty must be understood as a duty to assist the appellant in developing his claim, rather than a duty on the part of VA to develop the entire claim with the appellant performing a passive role. See Turk v. Peake, 21 Vet. App. 565, 568 (2008). In this case, because the appellant failed to provide the requested information, the Board finds that VA's duty to assist him in obtaining these records has been fulfilled, in compliance with the August 2011 remand. See Stegall, 11 Vet. App. at 268. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the appellant. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the appellant's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran VA examinations in February 2005, May 2010, and October 2011. The examinations are adequate because they are based on thorough examinations, a description of the appellant's pertinent medical history, and a review of the claims folder. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The appellant has not reported receiving any recent treatment specifically for this condition, and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the appellant's service-connected disorder since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The October 2011 VA examination report is thorough and provided findings pertinent to the rating criteria. The examinations in this case are adequate upon which to base a decision. The October 2011 VA examination also satisfied the requirements of the August 2011 Board remand. See Stegall, 11 Vet. App. at 268. The Board notes that the AMC issued a supplement statement of the case to the appellant at his last known address in September 2012, and it was returned to VA as undeliverable. None of the prior notices sent to the appellant at this address had been returned as undeliverable. In any event, the appellant did not notify VA that his address had changed. The duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In the normal course of events, it is the burden of the appellant to keep VA apprised of his whereabouts. If he does not do so, there is no burden on the part of VA to turn up heaven and earth to find him. See Hyson v. Brown, 5 Vet. App. 262, 264 (1993). 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 Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the appellant. Id. § 4.3. An appeal from the initial assignment of a disability rating, such as the appeal in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Mixed anxiety-depressive disorder is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code 9400. The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating (the maximum schedular rating) - 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. 70 percent - 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. 50 percent - 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 effective work and social relationships. 30 percent - 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, and mild memory loss (such as forgetting names, directions, recent events). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence shows that the Veteran 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, the appropriate equivalent rating will be assigned. Id. at 443. Global Assessment of Functioning (GAF) is 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) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)) (DSM-IV). According to DSM-IV, a GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates the examinee has some impairment in reality testing or communication or major impairment in several areas, such as work or school. A GAF score of 21 to 30 indicates that the examinee's behavior is considerably influenced by delusions or hallucinations, has serious impairment in communication or judgment, or is unable to function in almost all areas of life. A GAF score of 11 to 20 indicates that the examinee is in some danger of hurting self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication. A GAF score of 1 to 10 indicates persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death. See also QUICK REFERENCE TO THE DIAGNOSTIC CRITERIA FROM DSM-IV, 46-47 (1994). III. Analysis The appellant contends that he is entitled to an initial disability rating in excess of 30 percent for service-connected mixed anxiety-depressive disorder. For the reasons that follow, the Board concludes that a higher disability rating is not warranted. The appellant's claim for service connection for mixed anxiety-disorder was granted with an evaluation of 30 percent effective August 21, 2004. As such, the rating period on appeal is from August 21, 2004. 38 C.F.R. § 3.400(o)(2) (2011). The appellant was evaluated at a VA psychological examination in February 2005. The appellant reported having increased problems with short-term memory. The appellant reported feeling "depressed and anxious." He reported that he generally slept 4 to 5 hours at night, and sometimes woke up 2 to 3 times during the night. He reported nightmares of being attacked or reliving military experiences. Sometimes he sobbed in his sleep. He became depressed and anxious whenever he thought or talked about his wife or his military experience in Alaska. He denied any "serious" thoughts of suicide at that time. The appellant reported that he often forgot how to make the computer do what he want, forgot passwords, and forgot his work hours. He stated that he checked his hours repeatedly to remind himself of when he got off work. He drove, but he sometimes forgot where he was going. He occasionally walked out of the house without his keys or wallet. He reported that he was quite socially isolated. He had no active relationships with family members and no friends except his roommate. The appellant denied a history of substance abuse. He reported that he sometimes drank 1 to 2 drinks a night, but not every night. He reported that he was employed as a salesman, and the job was "going pretty well, but there are big memory issues." The appellant was separated from his wife. On examination, the appellant was friendly and talkative with an anxious mood and appropriate affect. He spoke rapidly. His speech tended to be tangential and he seemed preoccupied with feelings of resentment about how he had been treated by others. He showed little insight into what his role in his difficulties might have been. There was no evidence of fixed delusions. He denied hallucinations. He denied "serious" suicidal ideation, but reported significant depression and feelings of loss regarding his military career and marriage. He denied homicidal ideation. He was oriented in all spheres and displayed no significant problems with memory, concentration or abstract reasoning during the mental status examination. However, he was clearly having difficulties in these areas in his daily life. His judgment appeared fair. He denied compulsive behavior except in the area of repeatedly checking details he might otherwise forget, such as his work schedule. He reported he sometimes had difficulty sleeping at night. The appellant was diagnosed with anxiety disorder, not otherwise specified (mixed anxiety-depressive disorder). He had a GAF score of 51. The VA examiner noted that the appellant lived independently and appeared able to manage his own affairs and VA benefits. In a July 2005 substantive appeal, the appellant stated that he had difficulty understanding complex commands and had impaired short term and long term memory. He reported that his short and long term memory loss was apparent in everyday life (i.e. forgetting keys, days of week, important people, names, etc.) He stated that this put great stress and difficulty in establishing and maintaining effective work and social relationships. On a VA form 9, dated in February 2006, the appellant stated that when multiple orders were given to him, many times he failed to complete them, or if completed, would not be quality, because he could not remember how to do the tasks previously learned. He stated that for him to go to a social event, typically, someone else has to make him go. He reported that he has problems maintaining work and social relationships. The appellant was evaluated at another VA psychological examination in May 2010. The appellant said he was divorced and his relationship with his ex-wife was "better." He continued to have a distant relationship from his family. He continued to have difficulty making and maintaining friendships. He considered his roommate to be his only friend. He enjoyed video games, playing guitar, hanging out with his roommate and sometimes doing volunteer work. He was a full time student working on his Master's degree. Since his last evaluation, he had worked at Best Buy and Circuit City before quitting work to attend school full time. The appellant independently managed his hygiene, household chores and medication. He was able to drive. The appellant reported that he continued to have memory problems including forgetfulness, losing his train of thought, and word finding difficulties. He drank 2 to 3 mixed drinks 4 to 5 nights per week. He denied being hospitalized for psychiatric treatment since his last examination. He also reported that he had not received outpatient treatment for psychological problems since discharge. He denied a history of homicidal ideation, plan or intent. He denied problems with anger, but said he remained frustrated. The appellant denied symptoms of depression. He said he was not sad, tried to be optimistic, his appetite was fine, and his energy level was good. His sleep had improved but he did not go to sleep until 3 or 4 am and slept until 12 or 1 pm. The appellant stated that he thought about his military experiences daily and these thoughts brought up the emotions of anger and confusion and the physiological symptoms of shaking, voice shaking, and sweating accompanying the thoughts. He said he avoided talking about his experiences and avoided people and social situations. He was less interested in and participated less in activities that he used to enjoy such as group or team activities. No symptoms of generalized anxiety, panic, mania, psychosis or obsessive compulsive behaviors were noted. On examination, the appellant was appropriately groomed and casually dressed. His manner was cooperative. His eye contact was appropriate. Speech was unremarkable. Thought processes were logical and goal-directed. There was no evidence of hallucinations or delusions during the interview. Mood was appropriate to context. Affect was mood congruent. Homicidal and suicidal ideation, plan and intent were denied. The appellant was oriented to person, place, date and situation. With regard to concentration, he accurately completed the serial 7s task. He was also able to spell a five letter word forward and backward. Fund of basic information appeared good. Immediate retention was good. Judgment as assessed during the examination appeared fair. Insight appeared adequate. The diagnosis was anxiety disorder not otherwise specified. He had a GAF score of 55. The VA examiner stated that there had been improvement in his symptoms since his last examination in that his sleep and mood had improved, however, he continued to have significant difficulties in social functioning. He continued to have difficulty developing and maintaining relationships, both socially and occupationally. The VA examiner noted that the GAF score was 55 based on moderate psychiatric symptoms that cause functional impairment. Pursuant to the Board remand, the appellant was also evaluated at a VA psychological examination in October 2011. The VA examiner found the appellant had no mental disorder diagnosis. In regard to his social relationships, the appellant reported that he was still living in a house with a roommate and his relationship with his roommate was ok. He was not currently dating, but had a brief relationship a few months prior. The appellant had a few friends in Dallas that he talked with on a monthly basis. He stated that he had tried to make friends at school, but had been unsuccessful. He said that he enjoyed working, housework, yard work, and dabbling into studying business and creating business plans. He was a full-time student working on a master's degree. The VA examiner noted that since the appellant's last examination in May 2010, his anxiety symptoms had largely resolved. He said that once every month or two, he had panic-like symptoms that typically occurred in social situations. The symptoms lasted approximately 0.5 to 1 hour. The symptoms did not effect a change in behavior nor did he worry about having the symptoms. He reported that he was no long bothered by events that occurred during his military service. He said he continued to have problems with memory. He said that he would ask a question over again, not remembering that he had already asked it and that he forgot midsentence what his point was. However, a mini mental status exam was within normal limits. He reported that he always felt unhappy about his personal life, but had only felt depressed 2 or 3 times in the past 30 days. He reported fewer interests in activities. He also noted less interest in school. His appetite was good. His energy was ok and his concentration was fine. He denied thoughts of suicide or homicide. The VA examiner found the appellant did not have symptoms of clinically significant depression. The VA examiner concluded that the appellant's anxiety symptoms had largely resolved. While he was no longer bothered by the things that happened to him while he was in the service, he continued to have transient panic-like symptoms, typically in social situations, however, these symptoms did not cause clinically significant impairment or distress. Therefore, he no longer met the criteria for a psychiatric diagnosis. Based on the evidence of record, the Board finds that a rating in excess of 30 percent is not warranted for the appellant's service-connected mixed anxiety-depressive disorder. The appellant's symptoms during the period on appeal reflect that he had occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but the evidence does not reflect that the appellant had occupational and social impairment with reduced reliability and productivity. The evidence does not demonstrate that the appellant received treatment for his mixed anxiety-depressive disorder. The May 2010 VA examination report reflects that the appellant had not received outpatient treatment or been hospitalized for psychological problems since his discharge from the service. There is no indication that he was ever prescribed medication for the mixed anxiety-depressive disorder. During the period on appeal the appellant was employed full-time and then became a full-time student pursuing a master's degree. Although the appellant reported having memory problems, on examination, he did not demonstrate problems with his memory. The February 2005 VA examiner noted that the appellant displayed no significant problems with memory, concentration or abstract reasoning during the mental status examination. The evidence of record reveals no impairment of the thought process of communication. The appellant's symptomatology does not reflect that he has had speech that is intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, spacial disorientation or neglect of personal appearance and hygiene, or symptoms approximate to the level of severity of these symptoms. Although the appellant has reported difficulty establishing and maintaining social relationships, he has maintained a friendship with his roommate. He also reported that he talks to a couple of friends in Dallas on a monthly basis. See October 2011 VA examination report. Additionally, when evaluating the level of disability from a mental disorder, an evaluation is not to be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The appellant is competent to report symptom capable of lay observation and the Board finds his statements regarding his psychological symptoms to be credible. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds the appellant's statements regarding his symptoms to be credible, as they are consistent in the evidence of record. Although the appellant did not demonstrate symptoms of memory problems during the examinations, the Board finds his statements that he had memory problems in daily life to be credible. A 30 percent rating contemplates symptoms such as mild memory loss (such as forgetting names, directions, recent events). In the July 2005 substantive appeal, the appellant described symptoms such as forgetting keys, names, password and his work hours. At the October 2011 VA examination, he stated he would ask a question over again, not remembering that he had already asked it. However, a mini mental status exam was in normal limits. The appellant never showed memory loss on examination. His symptoms are similar to the symptoms contemplated by a 30 percent rating for mild memory loss. The appellant has reported having panic-like symptoms. The October 2011 VA examiner noted that the appellant continued to have transient panic-like symptoms, however, these symptoms did not cause clinically significant impairment or distress. At the February 2005 VA examination the appellant reported nightmares of being attacked or reliving military experiences. The October 2011 VA examination report indicates the appellant reported he was no longer bothered by events that occurred during his military service. A 30 percent rating contemplates symptoms such as panic attacks (weekly or less often). The Board finds the appellant's panic symptoms to be consistent with the symptoms contemplated in a 30 percent rating. The appellant also reported having sleep problems at the February 2005 VA examination. He reported nightmares of being attacked or reliving military symptoms. The appellant did not report significant sleep problems at the October 2011 VA examination and he reported that he was no long bothered by events that occurred during his military service. Moreover, chronic sleep impairment is one of the types of symptoms contemplated by a 30 percent rating. The appellant's GAF scores during the period on appeal were also consistent with a 30 percent rating. At the February 2005 VA examination, the appellant had a GAF score of 51. At the May 2010 VA examination, the appellant had a GAF score of 55 based on moderate psychiatric symptoms that cause functional impairment. At the October 2011 VA examination, the appellant had a GAF score of 70. As noted above, a GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. Mild to moderate symptoms of mixed anxiety-depressive disorder are consistent with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The appellant was evaluated at three VA psychological examinations during the period on appeal, but none of the examiners found that the appellant's symptoms were so incapacitating as to result in total occupational and social impairment. Nor has the appellant reported such incapacitation. He worked and was a full-time student during the period on appeal. At the February 2005 VA examination, the appellant denied "serious" suicidal ideation, but reported significant depression. At the May 2010 and October 2011 VA examination, the appellant denied having suicidal ideation. The appellant consistently denied having homicidal ideation. At all times, the appellant has been found to be oriented in all tested spheres and capable of expressing himself in a coherent and logical manner and he has retained good communication skills. The appellant did describe having memory problems and problems maintaining social relationships. However, the majority of his symptoms indicate he had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Board has carefully considered the appellant's contentions and arguments, however, the Board finds that the preponderance of the evidence does not support assignment of any higher rating. Both the symptoms and overall impairment caused by the Veteran's psychiatric disability most closely approximate a 30 percent rating. Thus, the Board finds that the preponderance of the evidence is against an allowance of an initial rating in excess of 30 percent for mixed anxiety-depressive disorder. The Board has considered whether a staged rating is appropriate for the mixed anxiety-depressive disorder. The evidence of record reflects that the appellant's disorder improved during the period on appeal. The October 2011 VA examiner concluded that the appellant's anxiety symptoms had largely resolved. He found that the appellant no longer met the criteria for a psychiatric diagnosis. However, the appellant still had problems with social relationships and some anxiety symptoms. Therefore, the Board finds that there was not enough variation in the appellant's symptomatology or clinical findings for the manifestations of the disorder that would warrant the assignment of a staged rating. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has also considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the mixed anxiety-depressive disorder. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected psychiatric disability. The Veteran's disability is manifested by impairment in social and occupational functioning. The rating criteria contemplate these impairments; hence, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). The Board acknowledges that the appellant, in advancing this appeal, believes that his disability has been more severe than the initially assigned disability rating reflects. However, as discussed above, the Board finds the appellant's symptoms are not congruent with a higher initial rating. As noted above, the appellant is competent to report symptoms capable of lay observation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds him credible as his statements are consistent throughout the period on appeal. However, the Board finds the appellant's symptoms, as described by the appellant, to be consistent with a 30 percent initial rating. A claim for a total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised 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. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In this case, the appellant has not argued, and the record does not otherwise reflect, that the disability at issue renders him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. In conclusion, the board finds that a preponderance of the evidenced is against the appellant's claim for an initial rating in excess of 30 percent for mixed anxiety-depressive disorder. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to an initial disability rating in excess of 30 percent for service-connected mixed anxiety-depressive disorder is denied. REMAND 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). In regard to the appellant's service connection claims, the Board finds that there has not been substantial compliance with the mandates of the August 2011 Board remand. The Board requested that the appellant be afforded VA examinations to determine the etiology of the appellant's claimed bilateral ankle sprain, right wrist sprain and bilateral knee sprain. The Board noted that the appellant was diagnosed as having bilateral ankle sprain, right wrist sprain and bilateral knee sprain only a few months following separation. See February 2005 VA examination. In addition, service treatment records dated in December 2000 showed X-ray findings of a probable bone island at the base of the proximal phalanx of the fifth digit of the right hand and the appellant stated that he was treated during service for bilateral knee pain. The VA examiner was instructed to specifically discuss the February 2005 diagnoses of bilateral ankle sprain, right wrist sprain and bilateral knee sprain, the December 2000 X-ray findings of a probable bone island at the base of the proximal phalanx of the fifth digit of the right hand, and the appellant's report of in-service treatment for bilateral knee pain. Although the appellant's ankles, wrist and knees were evaluated at a VA examination in October 2011 and the VA examiner opined that the conditions were less likely than not incurred in or caused by service, the VA examiner did not provide a thorough rationale for the opinions. The VA examiner noted that the appellant did not have any ankle, right wrist, or knee conditions, and that there was no evidence of complaints in the service treatment records. However, the VA examiner did not address the findings of the February 2005 VA examination. As the VA examiner did not address the results of the February 2005 VA examination as instructed by the Board, the VA examination is inadequate. Thus, the claim must be remanded for a new VA examination. Further, in the August 2011 the Board noted that in the December 2009 remand, it had requested the RO to clarify whether the RO decision denying service connection for "dermatitis/ankle sprain" in the rating decision on appeal was orthopedic or dermatological after the examination on remand. The Board requested that the agency of original jurisdiction (AOJ) correct this deficiency. However, at the October 2011 VA examination the examiner did not address whether the appellant had dermatitis on his ankles. Additionally, the AOJ did not include any discussion in the September 2011 supplemental statement of the case clarifying whether the decision with regard to the ankles was orthopedic or dermatological. Thus, on remand, the AOJ should clarify whether the grant of service connection for dermatitis of the feet should also include the ankles. In regard to the appellant's service-connected right shoulder disability, in the August 2011 remand, the Board requested that the AOJ schedule the appellant for a VA examination to determine the nature and extent of the appellant's service-connected right shoulder disability. The October 2011 VA examiner provided an opinion regarding the etiology of the appellant's right knee disability. The VA examiner stated that the appellant had a normal examination without any indication of abnormality or disability. However, it does not appear that the specific results of the examination have been associated with the claims file. As it appears the VA examiner examined the right shoulder but a copy of the examination report was not added to the claims file, the claim must be remanded to obtain a complete copy of the examination report. If the appellant's right shoulder symptomatology was not fully evaluated at the October 2011 VA examination, then a VA examination is necessary to ensure compliance with the Board's previous remand order. The appellant's right great toe disability was also evaluated at the October 2011 VA examination. In the August 2011 remand, the Board noted that the May 2010 VA examiner found that there was no diagnostic evidence or labs consistent with gouty arthritis of record and examination, including X-ray findings, showed early minimal degenerative changes in the first metatarsophalangeal joint with no evidence of erosive lesions consistent with gouty arthritis. The examiner opined that the early degenerative changes were consistent with great right toe strain and were at least as likely as not related to the service. The Board found this examination inadequate as no diagnosis was provided for the appellant's current disability of the right great toe. The Board requested another examination in which the examiner was instructed to discuss the extent of any incoordination, weakened movement, and excess fatigability on use, objective evidence of pain or functional loss due to pain, and specific functional impairment due to pain. However, in the October 2011 VA examination, the examiner did not discuss these issues. The VA examiner stated that imaging studies of the foot had been performed and there were no abnormal findings. The examiner also stated that the appellant did not have a toe disability. However, he did not address the May 2010 VA X-ray findings showing early minimal degenerative changes. A copy of the imaging studies relied on by the October 2011 VA examiner has not been associated with the claims file. Consequently, the claim must be remanded for a complete examination of the great right toe, including a discussion of the minimal degenerative changes found at the May 2010 VA examination. Any imaging studies from the October 2011 VA examination should also be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Obtain a complete copy of the October 2011 VA examination report, including the detailed findings of the right shoulder examination and the imaging studies of the right great toe referenced by the VA examiner. If these records are not available, a negative reply is required. 2. After completion of #1, provide the claims file to an appropriate specialist to provide an opinion as to the etiology of the claimed bilateral ankle condition, right wrist sprain, and bilateral knee sprain. The VA examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e. whether there is at least a 50 percent probability) that any bilateral ankle condition, right wrist sprain, and bilateral knee sprain had their onset during active service or is related to any in-service disease or injury. The examiner must specifically discuss the February 2005 diagnoses of bilateral ankle sprain, right wrist sprain, and bilateral knee sprain; the December 2000 X-ray findings of probable bone island at the base of the proximal phalanx of the fifth digit of the right hand; and the appellant's report of inservice treatment for bilateral knee pain. With regard to the claimed bilateral ankle condition, if the appellant is diagnosed with a dermatological condition, the examiner should offer an opinion as to whether the condition is related to the service-connected dermatitis of the bilateral feet or a separate condition. The VA examiner is requested to provide a thorough rationale for any opinion provided. If the clinician is unable to provide an opinion without resorting to speculation, the clinician should explain why a definitive opinion cannot be provided. 3. After completion of #1, schedule the appellant for a VA orthopedic examination to determine the nature and extent of the service-connected right great toe disability. The claims file must be made available to the examiner for review prior to the examination. All necessary tests should be conducted and the examiner(s) should review the results of any testing prior to completion of the report. All pertinent pathology should be noted in the examination report. The examiner should discuss the extent of any incoordination, weakened movement, and excess fatigability on use; objective evidence of pain or function loss due to pain; and specific functional impairment due to pain. The examiner should comment on whether the appellant has been diagnosed with gout during the period on appeal. If the appellant has been diagnosed with gout, the examiner should provide an opinion as to whether it is at least as likely as not that the gout was incurred in service. The examiner should reconcile the May 2010 VA examination, which found the appellant had early minimal degenerative changes in the right great toe and the October 2011 VA examination, which found the appellant did not have a right great toe disability. If the appellant has degenerative changes in the right great toe, the examiner should provide an opinion as to at least as likely as not (i.e. whether there is at least a 50 percent probability) incurred in service or caused or aggravated by his service-connected great right toe strain. The VA clinician is requested to provide a thorough rationale for any opinion provided. If the clinician is unable to provide an opinion without resorting to speculation, the clinician should explain why a definitive opinion cannot be provided. 4. After completion of #1, if the complete October 2011 VA examination report does not include a full evaluation of the appellant's right shoulder symptomatology, schedule the appellant for a VA orthopedic examination to determine the nature and extent of the service-connected right shoulder disability. The claims file must be made available to the examiner for review prior to the examination. All necessary tests should be conducted and the examiner(s) should review the results of any testing prior to completion of the report. All pertinent pathology should be noted in the examination report. The examiner should discuss the extent of any incoordination, weakened movement, and excess fatigability on use; objective evidence of pain or function loss due to pain; and specific functional impairment due to pain. The VA examiner is requested to provide a thorough rationale for any opinion provided. If the clinician is unable to provide an opinion without resorting to speculation, the clinician should explain why a definitive opinion cannot be provided. 5. Thereafter, readjudicate the issues on appeal. The AOJ should specifically consider whether any diagnosed bilateral ankle condition is a skin condition or orthopedic. If any benefit sought is not granted, issue a supplemental statement of the case and afford the appellant an appropriate opportunity to respond. The case should then be returned to the Board, as warranted. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs