Citation Nr: 1305443 Decision Date: 02/14/13 Archive Date: 02/21/13 DOCKET NO. 12-06 497 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUE Entitlement to a higher initial rating for service-connected anxiety disorder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from December 1943 to February 1946. This case comes to the Board of Veterans' Appeals (Board) on appeal from an April 2011 decision of the RO in Roanoke, Virginia that granted service connection and a 10 percent rating for anxiety disorder not otherwise specified (NOS). The Veteran appealed for a higher rating. A personal hearing was conducted before a decision review officer of the RO in June 2012, and a Board videoconference hearing was held before the undersigned Acting Veterans Law Judge in December 2012. Transcripts of both hearings are of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Resolving all reasonable doubt in his favor, the Veteran's anxiety disorder NOS causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria are met for a higher initial rating of 30 percent, but no greater, for anxiety disorder NOS. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist a claimant 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). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). The requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between a Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule); Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, a letter satisfying the notice requirements of 38 C.F.R. § 3.159(b)(1) as concerning the Veteran's initial claim for service connection for a psychiatric disorder (claimed as posttraumatic stress disorder (PTSD)) was sent to him in June 2010. The issue of the evaluation to be assigned to the now service-connected anxiety disorder NOS is a "downstream" issue. In cases such as this, 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 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, supra; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board notes that although the Veteran initially claimed service connection for PTSD, the RO properly expanded the claim to include any mental disorder that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record, and ultimately established service connection for anxiety disorder NOS. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons, the United States Court of Appeals for Veterans Claims (Court) indicated that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Once a notice of disagreement has been filed contesting the "downstream" issue of the initial rating assigned for a disability, the notice requirements of 38 U.S.C. §§ 5104 and 7105 regarding a rating decision and statement of the case control as to the further communications with the appellant, including as to what evidence is necessary to establish a more favorable decision with respect to this downstream element of the claim. Id.; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) and VAOPGCPREC 8-2003 (Dec. 22, 2003). And the Veteran received this required statement of the case in March 2012 and a supplemental statement of the case in October 2012, discussing this downstream claim for a higher initial rating, citing the applicable statutes and regulations, and providing reasons and bases for not assigning a higher rating. The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). That burden has not been met in this case. VA also fulfilled its duty to assist the Veteran with this claim by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO obtained his service treatment records (STRs), VA outpatient treatment records, and private medical records, and arranged for VA compensation examinations in March 2011 and September 2012 to assess the severity of his service-connected anxiety disorder, which, as mentioned, is now the determinative downstream issue. The Board notes that at his June 2012 hearing, the Veteran's representative essentially asserted that the latest VA examination was inadequate, because PTSD was not diagnosed. However, the Board finds that both VA compensation examinations were adequate, as they were performed by competent medical professionals, and the reports of those examinations contain the findings needed to determine whether the rating for the service-connected psychiatric disorder should be increased. Only if the record is found to be inadequate or there is a suggestion that the current rating may be incorrect is there then a need for a more contemporaneous examination. 38 C.F.R. § 3.327(a) (2012). Here, the most recent VA compensation examinations for these disabilities were in March 2011 and September 2012, so relatively recently. The mere passage of time since does not, in and of itself, necessitate another examination. Cf. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (discussing this in the alternative context of a claim for service connection). The Board therefore is satisfied that VA has provided all assistance required by the VCAA concerning this claim. 38 U.S.C.A. § 5103A. The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Law and Regulations It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "it is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Id. Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, as in this case, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran contends that his service-connected anxiety disorder NOS is more disabling than currently evaluated. The RO has rated the Veteran's service-connected anxiety disorder NOS as 10 percent disabling under Diagnostic Code 9411. 38 C.F.R. § 4.130, Diagnostic Code 9413. The Fourth Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. When evaluating a mental disorder, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disorders: a 10 percent rating is warranted for 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; symptoms controlled by continuous medication. In order to obtain the next-higher 30 percent rating, the evidence must show 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). 38 C.F.R. § 4.130, Diagnostic Code 9413. A 50 percent rating is warranted 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 requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); see also 38 C.F.R. § 4.130. In determining whether the Veteran meets the criteria for an increased rating, the Board must consider whether the Veteran has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). In evaluating the evidence, the Board also has considered various Global Assessment of Functioning (GAF) scores contained in the DSM-IV, which clinicians have assigned. A GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence bearing on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. The higher the score, the higher the overall functioning of the individual. A score of 51-60 represents 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). DSM-IV at 46-47. See 38 C.F.R. § 4.130. A score of 61-70 illustrates 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, has some meaningful interpersonal relationships. Id. A score of 71-80 is assigned when, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social occupational or school functioning (e.g., temporarily falling behind in schoolwork). A June 2010 new patient intake note from a private physician, J.S.D., MD, reflects that the Veteran presented for psychiatric evaluation. He was referred by the Vet Center. He reported traumatic incidents during his World War II service, and said he had experienced survivor guilt. He had intrusive recall of war events. He had no past psychiatric history or hospitalization, but had received therapy at a Vet Center. He had been married for 55 years, and said his wife was not concerned about his mental status. On mental status examination, he did not maintain good eye contact. He tended to focus on past experiences from the war. He was not a danger to himself or others, and was alert and oriented. He continued to have flashbacks about the trauma. The Axis I diagnosis was combat related PTSD. The GAF was 55-60. Zoloft was prescribed. On VA psychiatric compensation examination in January 2011, the Veteran denied any psychiatric treatment, but he reported one visit to a psychiatrist to determine his competence in the past few years. He reported in-service stressors, including rescuing sailors from the burning USS Bunker Hill when he was stationed on the USS English. The examiner indicated that the reported stressors met the DSM-IV criteria. The Veteran reported that after service he went to work in a restaurant and worked in restaurants for his entire life until he retired 20 years ago. He was married in 1956, and after 55 years his wife broke her hip. After she left the hospital, she stayed with their daughter, a nurse, and then filed for separation and then divorce. He said the divorce was not yet final. He stated that he had a good relationship with his wife before this, and he was not sure why she pursued a divorce. He said he did not have a good relationship with his daughter. He reported that he did not see or talk to friends much anymore. He had a good relationship with two siblings, and recently reestablished a relationship with another sibling, but had no relationship with another sister and brother. He currently spent his time going to the barber shop and talking to people there. He reported fist fights when he was younger but denied recent assaultiveness. He denied suicide attempts. On mental status examination, the Veteran displayed no impairment of thought process or communication. No delusions or hallucinations were noted. He made good eye contact and his behavior was appropriate throughout the examination. He denied suicidal or homicidal ideation. He was able to care for his activities of daily living. He was oriented to person, place, and time. He denied memory loss. He denied obsessive or ritualistic behavior, and rate and flow of speech was normal. He denied panic attacks. He reported some depression over the recent separation and pending divorce but said this had lessened. He denied anxiety or impaired impulse control. He reported that he had not slept well since the Navy. He said he used to get only two to three hours of sleep and now reported that he was up and down all night, and at times he woke up due to dreams. The examiner diagnosed anxiety disorder NOS, and opined that the Veteran did not appear to meet the full symptoms criteria for PTSD. However, the symptoms of PTSD that he has experienced did appear to have affected his social relationships as he does not maintain friendships or significant relationships with his family and has reduced significant relationships with his family. In addition, he does not have significant leisure pursuits. He worked consistently after the military until he retired approximately 20 years ago. Thus, he does not appear to have had occupational impairment due to his PTSD symptoms. The Veteran reported actively avoiding things that reminded him of the war or the current war, although he did report feeling a need to care for the war memorial because of the deceased veterans. The examiner indicated that overall, the Veteran appeared to have had mild social impairment from his symptoms of PTSD. The GAF was 65. In a March 2011 addendum, the January 2011 VA examiner noted that the claims file was reviewed. The examiner indicated that the Veteran's symptoms of anxiety and diagnosis of anxiety disorder NOS were related to his symptoms of PTSD from his involvement with the rescue of the USS Bunker Hill during service. At the time of the examination, the Veteran met the stressor criteria for this involvement, but although he had multiple symptoms of PTSD, he did not meet the full criteria for a diagnosis of PTSD and was given a diagnosis of anxiety disorder NOS. The examiner opined that this disorder was most likely caused by or a result of his involvement in that rescue. VA medical records dated from June 2011 to October 2012 reflect treatment for a variety of medical conditions, but do not show ongoing treatment for a psychiatric disorder. Such records include lists of the Veteran's current medications, and do not show that the Veteran is currently taking any medication for a psychiatric disorder. VA inpatient records dated in June 2011 reflect that the Veteran was hospitalized for a cardiac condition. During the hospitalization, it was noted that he was depressed due to his divorce. In a psychiatric consult on admission, he reported that he had some nightmares, excessive startle and vigilance in the past after World War II, but PTSD symptoms had not been very frequent or impairing in recent years. The examiner indicated that he had no morbid, nihilistic, or suicidal thoughts, intent, plans or attempts, and no homicidal ideation. He said he was unexpectedly and recently divorced after many years of marriage, and had some increased social isolation and grief initially, but that was resolving. He socialized almost daily and hung out at a neighborhood barber shop. He had some friends in addition to his brother for support. His mood had been gradually improving in recent months. He denied feeling hopeless, helpless , or worthless, increasingly tearful or guilty. He denied obsessions, compulsions, panic symptoms, mania, hallucinations or delusions. Sleep and appetite were stable, and he denied forgetfulness, disorientation or confusion. He denied receiving inpatient or outpatient psychiatric treatment. On mental status examination, he was pleasant and friendly, made good eye contact, and easily established rapport. He had no psychomotor changes. His speech was linear, logical and goal directed. He enjoyed reminiscing. His speech had a normal rate, volume and tone. His mood was OK with full stable affect. He denied hallucinations, delusions, paranoia, ideas of reference, suicidal or homicidal ideations. He was alert and oriented times four. Attention and concentration were full. Remote and recent memory were intact. Insight and judgment were good. The Axis I diagnosis was uncomplicated grief reaction, marital problem, and PTSD, per history. The GAF was 60. A referral for counseling was offered, but the Veteran declined. At a June 2012 RO hearing, the Veteran reported psychiatric symptoms including flashbacks about events in service, and said he cried during his sleep. He also reported recurrent thoughts of his war experiences, and sleep impairment. He said he first sought psychiatric treatment one or two years ago. He said he enjoyed talking to other veterans at a veterans care center and at the Vet Center. He reported that he was recently divorced from his wife of many years, but did not know why. By a letter dated in August 2012, a social worker from a Vet Center indicated that the Veteran presented to the Vet Center in July 2010 seeking assistance with PTSD symptoms, generalized anxiety and depression. His symptoms included frequent anxiety, daily intrusive thoughts of his wartime experiences, especially the events surrounding the USS Bunker Hill, marked sleep disturbance with difficulty falling asleep and periodic nightmares, avoidance of things that reminded him of the war or talking about the war, a diminished interest in activities, and depression with crying spells. His symptoms were easily triggered by seeing a fire or smoke either on television or in his community, news of the current war, war movies or documentaries, lightning, playing of the national anthem, and military or memorial services. He had participated in individual psychotherapy and PTSD group counseling. Any progress to date had been easily offset by any additional stress in his life. On VA psychiatric compensation examination in September 2012, the Veteran reported that he lived alone after an unexpected divorce after 55 years of marriage. The examiner stated that the Veteran and his records suggested that the divorce may have had more to do with money issues and their daughter. The Veteran reported some distance from some of his siblings, which he felt was due to jealousy that he did well in his business and in his life. He got along well with two brothers and one sister. He visited his brother for one month in the summer and had a great time. He related that he had a lot of friends when he had his business, but after he retired due to a spine disability, his friends stopped coming around as much. He was friendly with his neighbor. He enjoyed going to Vet Center support groups and went to the DAV at times. Previously, he went to the DAV three to four times per week, but had been going less often since his move due to the cost of gas for his car. He had been going to church regularly but had not been going lately since he was ashamed of the divorce. He also said his former wife had filed a restraining order against him, but this was likely out of spite as he denied any threats, violence, assault, etc. He walked and visited people at a barber shop. He stated that in the past, he worked seven days a week, 18 hours a day at his own restaurant. He did his own errands and liked talking to people in stores. He reported no distress at such places. He seemed to enjoy talking to people and said he got along with everybody. He said that when he was working, he got along well with his employees in the kitchen and enjoyed talking and joking with customers. The examiner noted that he regularly attended support groups at the Roanoke Vet Center, but other than that, had no mental health treatment since his last examination. He had been on no psychiatric medications and did not seem to need that level of mental health care. The examiner indicated that the Veteran had chronic sleep impairment, and did not list any other psychiatric symptoms. The examiner opined that the Veteran had only some mild mental health symptoms and seemed to have been coping well overall, with no significant impairment in his life. He worked regularly operating his own restaurant for years until his spine problems forced retirement 20 years ago. It seemed that his recent divorce was not related to any mental health issues on his part. He got along with some siblings but not others, but attributed this to issues other than his mental health symptoms. On examination, his affect was broad, and mood was euthymic. He was friendly, talkative, and cooperative, and smiled and joked at times. He appeared in no significant emotional distress. Eye contact, speech and behavior were normal. There were no delusions or hallucinations. He denied suicidal or homicidal ideation. There were no panic attacks or obsessive compulsive disorder. Memory was intact. He denied any problems with pervasive depression and stated that he stayed happy pretty much all the time. There was also no pervasive anxiety, though he did describe some normal worries such as regarding finances. He reported some sleep problems, estimating that he tended to get four to five hours per night, and six hours was a good night. He speculated that his sleep problems might be due to his brief sleep schedule for many years when he was working. The examiner stated that while the Veteran did not have PTSD, he did have some World War II trauma-related symptoms that are what prompted the diagnosis of anxiety disorder NOS. Today, the Veteran continues to report that he periodically has upsetting memories of his World War II trauma in the Navy, which occurred two to three times per week. He was not clear that he had war-related nightmares. He did not describe any significant startle, vigilance, anger/irritability, or significantly impaired concentration. The examiner stated that the few periodic symptoms he has produce subjective distress at times, but he did not seem to have symptoms that rise to the level of causing clinically significant distress or impairment in social, occupational or other important areas of functioning. The diagnosis was anxiety disorder NOS, and the GAF was 71. No other psychiatric disorders were diagnosed. The examiner indicated that the Veteran had 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, symptoms controlled by medication. At his December 2012 Board hearing, the Veteran reiterated many of his assertions. He reported psychiatric symptoms including recurrent thoughts of his war experiences, and crying in his sleep and when thinking about the war. He said his wife left him after 57 years because he was giving away too much stuff. He said he had given away a house, a vacant lot, and several automobiles, among other things. Considering all of the evidence of record, the Board notes that in September 2010, a private physician, Dr. D., diagnosed PTSD and assigned a GAF score of 55-60, indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social or occupational functioning, (e.g., few friends, conflicts with peers or co-workers). See DSM-IV at 46-47; see also 38 C.F.R. § 4.130. On VA examination in January 2011, the GAF was 65, indicating 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, has some meaningful interpersonal relationships. At a psychiatric evaluation during a June 2011 cardiac hospitalization, the GAF was 60, and the examiner related this to an uncomplicated grief reaction and marital problem. On VA psychiatric compensation examination in September 2012, the examiner indicated that the Veteran had 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, symptoms controlled by medication, and indicated a GAF of 71, reflecting symptoms that are transient and expectable reactions to psychosocial stressors, with no more than slight impairment in social occupational functioning. Thus, the Veteran's GAF scores have varied, but have generally been in the range reflective of moderate to mild symptoms, and never lower than moderate. The evidence of record also demonstrates that although Zoloft was prescribed in 2010, the Veteran has never been on continuous medication for service-connected anxiety disorder. He has received intermittent group and individual therapy for his psychiatric symptoms through the Vet Center. He has consistently reported severe sleep impairment and frequent intrusive thoughts about his war experiences, and frequent nightmares and/or crying in his sleep. So resolving all reasonable doubt in his favor, the Board finds that the Veteran exhibits the type, frequency and severity of symptoms required for a higher initial rating of 30 percent. 38 C.F.R. §§ 4.3, 4.7; Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding that the factors listed in the rating formula are mere examples of conditions that warrant a particular rating and are used to guide or help differentiate between the different evaluation levels; it is not an all-inclusive or exhaustive list). That is, the Board finds the Veteran demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 38 C.F.R. § 4.130. In addition to the medical evidence, the Board has considered the Veteran's personal assertions in support of his claim. He is competent, as a layman, to report on that as to which he has personal knowledge, such as sleeping difficulties, nightmares, and intrusive thoughts. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). And since his allegations of these particular symptoms appear to be uncontradicted, even by medical findings of record, the Board also finds them to be credible and, thus, probative. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). On the other hand, as a layman, without the appropriate medical training and expertise, the Veteran is not further competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his service-connected anxiety disorder in relation to the applicable rating criteria. An examiner, including the VA compensation examiner, takes into consideration the Veteran's subjective complaints, his social and occupational history, and the results of the objective mental status evaluation in determining the overall severity of his anxiety disorder NOS. So this determination is multi-factorial, not just predicated on his lay statements and hearing testimony, rather, all of the relevant medical and other evidence. And, here, although he is awarded a higher 30 percent initial rating, there is simply no evidence indicating the Veteran's anxiety disorder NOS has been so severe since the effective date of his award as to warrant an even higher rating of 50 percent or more. The Board finds that the weight of the evidence does not show the Veteran's anxiety disorder NOS has been so severe since the effective date of his award as to warrant a higher rating of 50 percent or more. The preponderance of the evidence, including VA and private psychiatric evaluations, simply does not show 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. Absent evidence of more symptoms indicating a higher severity of psychiatric dysfunction, the Board finds the evidence is against a disability rating greater than 30 percent for his PTSD. 38 C.F.R. § 4.3. Indeed, since his PTSD has never been more than 30-percent disabling at any time since the effective date of service connection, the Board cannot "stage" this rating. Fenderson, 12 Vet. App. at 125-26. In sum, resolving all reasonable doubt in his favor, the evidence supports increasing the initial rating from 10 to 30 percent throughout the rating period on appeal. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Beyond this, however, the preponderance of the evidence is against the claim, in turn precluding the assignment of any higher rating. Id. Extra-Schedular Consideration There is no evidence of exceptional or unusual circumstances to warrant referring this case for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1) (2012). See also Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds no evidence that the Veteran's service-connected anxiety disorder has markedly interfered with his ability to work, meaning above and beyond that contemplated by his schedular ratings for this disability, or necessitated frequent hospitalization, etc. In Thun, the Court clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the 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 under 38 C.F.R. § 3.321(b)(1). Under the approach prescribed by VA, if, as here, the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Veteran has not required frequent hospitalization for evaluation or treatment of the service-connected anxiety disorder. To the contrary, all of his evaluation and treatment for this disability has been on an outpatient basis, not as an inpatient, much less frequent inpatient. And there equally has not been any indication of marked interference with his employment, certainly none above and beyond that contemplated by the rating assigned for his anxiety disorder. The evidence reflects that he managed his own restaurant successfully for many years, and retired years ago due to a non-service-connected spine disability. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (reiterating that the disability rating, itself, is recognition that industrial capabilities are impaired). Hence, extra-schedular consideration is not warranted under the circumstances presented. See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER A higher 30 percent initial rating for anxiety disorder NOS is granted, subject to the laws and regulations governing the payment of VA compensation. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs