Citation Nr: 1306071 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 05-09 332 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased rating for dysthymic and generalized anxiety disorders rated as 30 percent disabling prior to August 2, 2007, and 50 percent disabling on and after that date. 2. Entitlement to an increased evaluation for bursitis of the right (dominant) shoulder, currently rated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is also the appellant, had active service from August 1978 to August 1981, October 1985 to February 1986, and March 1986 to September 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from various rating determinations of the Department of Veterans (VA) Regional Office (RO) located in Waco, Texas. The Veteran appeared at a Travel Board hearing before the undersigned Veterans Law Judge in July 2008. A transcript of the hearing is of record. In November 2008, the Board remanded this matter for further development. At the time of the prior remand, the issue of entitlement to service connection for a lumbar spine disability was also before the Board. Following the requested development, the RO, in an April 2012 rating determination, granted service connection for degenerative joint disease and resultant radiculopathy of the lower extremities. As this is the full benefit sought on appeal, the Board will no longer address this issue. The requested development has been substantially complied with and the matter is now ready for appellate review. FINDINGS OF FACT 1. Throughout the course of the appeal, the Veteran's dysthymic and generalized anxiety disorders have caused occupational and social impairment, with deficiencies in most areas, including obsessional rituals which interfere with routine activities; near-continuous panic or depression affecting the ability to functioning independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. 2. The Veteran's right shoulder bursitis was not shown to have limitation of motion midway between the side and shoulder level and was not manifested by ankylosis of the scapulohumeral articulation; impairment of the humerus involving recurrent dislocation at the scapulohumeral joint, malunion, fibrous union, false flail joint, or flail shoulder; or impairment of the scapula or clavicle. CONCLUSIONS OF LAW 1. The criteria for a 70 percent disability, but no more, for dysthymic and generalized anxiety disorders have been met throughout the course of the appeal. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.130, Diagnostic Codes 9433-9400 (2012). 2. The criteria for an evaluation in excess of 20 percent for right shoulder bursitis have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59. 4.71a, Codes 5003, 5024, 5200, 5201, 5202, 5203 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 has been amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. In a letters dated in May 2002 and July 2005, the RO provided the Veteran with notice that informed him of the evidence needed to substantiate entitlement to increased evaluations. The letters also told him what evidence he was responsible for obtaining and what evidence VA would undertake to obtain. A March 2006 letter complied with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), as it relates to the degree of disability and effective date of the disabilities. Although the Veteran received a portion of the VCAA notice after the original adjudication of his claim, he is not shown to be prejudiced by the timing of VCAA-compliant notice, as the RO readjudicated his claim in several supplemental statements of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the case (SOC) or SSOC, is sufficient to cure a timing defect). As it relates to all issues, VA has a duty to assist a claimant in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All available VA and private treatment records have been obtained. The Veteran was given an opportunity to submit evidence in support of his claim following the November 2008 Board remand. Neither the Veteran nor his representative have identified any additional evidence. The Veteran was afforded multiple VA examinations in conjunction with his claims. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examinations to be adequate for rating purposes. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments presented by his representative and through testimony at his July 2008 Travel Board hearing. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Increased Evaluations Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). Dysthymia and Generalized Anxiety Disorders The Veteran's dysthymic and generalized anxiety disorders are evaluated under 38 C.F.R. § 4.130, Diagnostic Codes 9433-9400. These Diagnostic Codes provide for a 30 percent evaluation for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is to be 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 evaluation 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. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation 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. 38 C.F.R. § 4.130, Diagnostic Codes 9433-9400. The symptoms cited above for the 70 percent and 100 percent ratings follow the phrase "such symptoms as" which indicates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the Board is not required to find the presence of all, most, or even some, of the enumerated symptoms for any particular rating. The list of symptoms merely provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH ED, American Psychiatric Association (1994) (DSM-IV), p.32; 38 C.F.R. §§ 4.125(a), 4.130 (2012). GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns, (e.g., an occasional argument with family members). Scores ranging between 71 to 80 reflect symptoms that are transient and expectable reactions by psychosocial stressors (e.g., difficulty concentrating after family argument, no more than slight impairment in social, occupational, or school functioning). Scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score of between 31 and 40 contemplates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). In conjunction with his claim, the Veteran was afforded a VA examination in October 2002. The Veteran was noted to be working as a guard at a Texas prison. The Veteran reported being chronically depressed with repeated temper outbursts and having difficulty controlling his impulse to hurt somebody. He stated that there had been no periods of remission. He noted that he found himself having difficulty with his supervisors and some inmates. He reported he was constantly on guard because he did not want to hurt anybody or get into trouble. Mental status examination revealed there was no impairment of thought process or communication. The Veteran denied hearing voices or experiencing any delusions. He stated that he heard people walking behind him when nobody was there. He had a blunted facial expression. He noted one suicide attempt during service but did not have any thoughts or plans. The Veteran maintained personal hygiene and performed activities of daily living. He was oriented to time, person, and place. There were no memory problems. There were also no obsessive or ritualistic behaviors. Rate and flow of speech was normal and he denied any problems with panic attacks. Mood was depressed with significant anxiety. Impulse control was claimed to be fragile but this was based upon what the Veteran stated and was not observed or reported from another source. The Veteran indicated that he had trouble maintaining a sleep pattern. He was also experiencing difficulty with anger management. Judgment and insight were fairly good. The examiner rendered a diagnosis of generalized anxiety disorder with depressive features. He assigned a GAF score of 51. The examiner noted that the Veteran was anxious, short-tempered, angry, and depressed most of the time and that this seriously impacted his work and social relationships. The examiner reported that the Veteran had serious symptoms of periodic suicidal/homicidal ideation and interactive disruptions. At the time of a December 2002 visit to the Scott and White Clinic, the Veteran reported that he was having work problems. He noted having problems with a co-worker which was causing difficulty with sleep, stress, anxiousness, and feelings of depression. He had had problems with this co-worker in the past. The Veteran reported having feelings of anxiety, anxiousness, and hopelessness. He denied any suicidal or homicidal thoughts. It was the examiner's impression that the Veteran had depression/situational stress. At the time of a September 2004 VA examination, the Veteran reported that he remained married to his second wife and had been married for 23 years. The Veteran indicated that his main problem was his short temper. He stated that he would get angry easily and that he stayed to himself in order to not get in trouble. He was not sleeping well. There were no periods of remission. The Veteran reported that he worked as a guard from 6 AM to 6 PM and that his job was stressful. He did not have any leisure time. He noted having problems with depression and stated that he was chronically depressed with temper outbursts. The Veteran reported having a short temper and getting angry easily. He also had difficulty controlling his impulse once he became angry. He noted that he had become pushy with another co-worker and that he had verbally assaulted an inmate. The Veteran had difficulty dealing with his supervisors, co-workers, and inmates, and stayed to himself. There had been no significant time lost from work. The Veteran was constantly on guard because he did not want to hurt anyone or get into trouble when he had these episodes of temper outbursts. He reported having anxiety attacks two times per week, relating to prison activities. He noted that this wife was very supportive but he did not tell her what was bothering him. Mental status examination revealed he was neatly dressed in casual attire. He had good eye contact and appropriate interaction. There was no impairment with thought process or communication. There were no delusions or hallucinations and he was not experiencing any delusional ideas. There was also no inappropriate behavior. The examiner noted that the Veteran reported hearing someone walking behind him when no one was there but this did not happen all the time. The Veteran denied any suicidal or homicidal plans or ideas. He maintained minimal personal hygiene and other activities of daily living. He was oriented to person, place, and time. While the Veteran reported being forgetful at times, his short and long term memory found to be intact. There was no obsessive or ritualistic behavior. Speech was normal and relevant. There were no obscure speech patterns. The Veteran denied significant problems with panic attacks but he noted having anxiety attacks two times per week. His mood was chronically depressed and he had been depressed for years. He also had anxiety about his situation. The Veteran noted having outbursts of temper and becoming easily angered, but he was able to control himself and not hit anyone. Sleep impairment was present and he woke up feeling tired. Judgment and insight were fairly good but the Veteran reported some difficulty with anger management, having a short temper, and becoming verbally loud or abusive. The examiner rendered a diagnosis of dysthymic disorder and assigned a GAF score of 52. The examiner indicated that most of the Veteran's stressors were related to his job, especially dealing with co-workers and the prison inmates. The severity was reported as moderate in nature. At the time of a December 2004 outpatient visit, the Veteran was noted to have a long standing history of dysthymia. The Veteran reported occasionally hearing voices but could not tell what they were saying. This had not occurred for several years. He was not suicidal or homicidal. He denied self-injurious behavior. The Veteran enjoyed being with his wife sometimes when they were not arguing. He worked as a prison guard and reported having trouble controlling his anger with inmates and co-workers. Mental status examination revealed he was a rather psychomotor retarded individual who made fair eye contact and developed limited rapport. His thoughts were coherent and goal directed. He denied suicidal or homicidal ideations and any recent auditory hallucinations or visual hallucinations. Speech was a little slow with diminished range of intonation. He started with decreased volume, which increased to about normal during the interview. Mood was depressed and affect was blunted. Insight was limited but judgment seemed fair. He was oriented to time, person, and place. From January 2005 through March 2005, the Veteran attended group therapy for anger management. At the time of a June 2005 VA outpatient visit, the Veteran was noted to be doing much better with anger management. The examiner rendered a diagnosis dysthymic disorder by history with superimposed major depressive disorder and assigned a GAF score of 60. In August 2005, the Veteran was afforded an additional VA psychiatric examination. He again reported having been married for 23 years. The Veteran noted working 12 hours per day four days per week as a prison guard. He reported having been depressed for the past four years and staying depressed most of the time. He noted hearing voices at times. The Veteran stated that the voices advised him at least once a month and sometimes complained of his way of life. He denied any suicidal or homicidal thoughts. He complained of having anger problems and easily losing his temper. The Veteran had a tendency to argue with his co-workers and it was confrontational on occasion, sometimes pushing people. He was trying to control his temper. Once he was home he did not want to leave. He reported having remissions of depression three to four times per month but he was otherwise depressed most of the time. He noted having lost 40 to 50 days of work in the past year as he did not show up for work at times because he was feeling nervous and depressed. Mental status examination revealed no impairment of thought process or communication. There was no evidence of hallucinations or delusions. He was in good contact with reality. The Veteran denied any suicidal/homicidal thoughts. He maintained minimal personal hygiene and performed activities of daily living. He was oriented to time, person, and place. There was no evidence of any memory impairment and no evidence of obsessive or ritualistic behavior. His speech was relevant and normal in rate and rhythm. The examiner indicated that there was no history of panic attacks and no evidence of them on examination. As to impulse control, the Veteran reported losing control due to anger problems but had not pushed anybody in the past three years. He was pretty much able to control his anger. The examiner indicated that the Veteran was suffering from long-standing depression but it was not affecting his work. He was noted to have been working fairly regularly. The examiner rendered a diagnosis of dysthymic disorder, late onset, and assigned a GAF score of 80. At the time of a November 2005 VA outpatient visit, the Veteran was diagnosed as having stable dysthymic disorder and major depressive disorder, with a GAF score of 60 being assigned. At the time of a May 2006 outpatient visit, the Veteran was noted to be performing his job as a prison guard well with diagnoses of dysthymic disorder and major depressive disorder being rendered, with a GAF score of 60 being assigned. At the time of a November 2006 VA outpatient visit, the Veteran reported having psychotic symptoms (paranoia and unformed audio hallucinations). The examiner rendered a diagnosis of major depressive disorder with psychosis and assigned a GAF score of 60. In a March 2007 report, the Veteran's psychosis was noted to be in partial remission. Mental status examination revealed he was not floridly psychotic. The examiner rendered a diagnosis of major depressive disorder with psychosis and assigned a GAF score of 60. At the time of an August 2007 VA examination, the Veteran reported that he had been doing better with his sleep and with his auditory hallucinations since he was put on risperidone. He stated that his mood was somewhat better but he was still dealing with a great deal of anxiety. He indicated that he was fearful of going anywhere there was a crowd. He had panic attacks when he went into public. He did not go out in public very much and this was a way to keep the panic attacks down. He reported having panic attacks once or twice a month. The Veteran indicated that he had an incident at work where he heard a voice and nearly hit a co-worker in the head with a first aid box. He got into a lot of trouble as a result of this and was put on probation for six months. He also had a road rage incident close to that time where he nearly pulled someone out of their car. He indicated that after those episodes he became afraid to go anywhere and started being fearful of leaving the house. He also noted becoming very depressed at that time. The Veteran stated that he was always somewhat depressed but that he would go into deeper spells of depression. The deeper spells would last 5 days to two weeks. During those periods of time, he did not want to leave the house or take a bath and he had no energy. He also stated that the voices were worse during those times. He indicated that the voices were of people that had passed away. He reported that he was able to come out of this after a week or so. The Veteran indicated that he had lost about 15 to 20 days of work in the past six months. He noted that during the deeper spells of depression he did not care. The Veteran indicated that when he went to work during these times he did the best he could. He stated that he verbally went off on co-workers and inmates. He also noted going off verbally at home with his wife but he stated that she understood his problems. His symptoms had also affected his performance reviews at work. During the past year he had had six verbal reprimands from his captain for not doing things the appropriate way. He noted that during the times he was feeling bad he did not send inmates to an activity. The Veteran reported that he was always depressed but that he cycled in and out of deeper depression, which lasted 5 days to two weeks. When in deeper depression he could not make himself go to work. He went to work and then went home in an effort to stave off panic attacks, which occurred one to two times per month anyway. He described his depression as a 7 on a scale of 1 to 10. He indicated that his anxiety level was a 5 and had been an 8 or 9 at its worst. Mental status examination revealed he was clean and appropriately shaved. His mood was anxious and his attention was distractible. His speech was slow and spontaneous. He was oriented times three and his thought process was unremarkable. As to thought content, the Veteran was focused on his anxiety and depression. He acknowledged that voices had been a part of his mental health problem over time. His judgment was fair; he understood the outcome of his behavior and could not get himself to do what he had been asked to do when he was feeling especially bad, even though part of him was aware that this choice was not appropriate. He stated that at times an "I don't care" attitude took over. Intelligence was average to below. As to insight, he understood that he had a problem and attempted to avoid problems with his anger or anxiety by isolating when not at work. He had some problems with short-term memory. Auditory delusions had been present off and on since his nervous breakdown in 2003, during which time he had a highly anxious mood, paranoia, depression, and auditory hallucinations. The hallucinations had gotten much better since risperidone was added. He indicated that his hallucinations were worse when his depression was worse. He denied any suicidal or homicidal ideations or plans. The Veteran maintained hygiene and performed activities of daily living. As to ritualistic or obsessive behavior, the Veteran did not touch door knobs with his hands and washed his hands many times per day. He also checked the locks two to three times on his house after going to bed. He had panic attacks whenever he was around too many people. He darted in and out of the grocery store. The Veteran had panic attacks one to two times per month. The panic attacks limited his willingness to leave his house or go where there were a lot of people. Impulse control was noted as fair. After the incident where he hit a co-worker and the road rage incident, the Veteran isolated for fear that he would lose control of his anger impulses. The Veteran stated that when angry he would go off verbally at co-workers and inmates. Axis I diagnoses of major depression with psychotic features in partial remission; dysthymic disorder; and panic disorder with agoraphobia, were rendered. The examiner assigned a GAF score of 58. He indicated that there was reduced reliability and productivity due to the Veteran's psychiatric problems. In an August 2007 treatment record, the Veteran was noted to be stable mood wise and to still be hearing voices. He continued to work as a prison guard. Mental status examination revealed he was neat and casually dressed. His behavior was calm and he was cooperative during the interview. His speech had a normal rate, rhythm, and volume. His mood was "fine" and his affect was appropriate. He was not floridly psychotic. He was not homicidal or suicidal and cognition, insight, and judgment were intact. The examiner rendered a diagnosis of major depressive disorder with psychosis. He assigned a GAF score of 60. At an October 2007 visit, the Veteran reported having insomnia and having a few hypnopompic hallucinations of his name being called. The examiner rendered a diagnosis of depression complicated by dysthymia and chronic pain and assigned a GAF score of 58. At the time of his July 2008 hearing, the Veteran testified that he started hearing voices in 2003. He stated that the voices affected his decision making when they first started. He also reported that he began having problems being around people at that time. He stated that he was essentially at home and by himself. The Veteran reported that when working at the prison he had problems fighting, pushing, and yelling at the inmates and guards. He stated that he physically assaulted one officer. He also noted that he was having memory problems in 2003. The Veteran stated that he would get agitated during the day and yell at his wife. The Veteran's wife testified that the Veteran's anger could be triggered by anything. She noted that she could calm him down when he was at home. She stated that she had to leave the house once or twice a year because the Veteran would become so angry. The Veteran indicated that he was running out of leave because he had to take time off for his various disabilities. At an October 2008 outpatient visit, the Veteran reported he was doing well overall and denied any psychotic symptoms. His main complaint was difficulty sleeping. He was casually dressed, cooperative, and had fair eye contact. Mood was good and affect was appropriate. Speech had a normal rate and rhythm. There were no motor abnormalities and thoughts were logical and goal directed with intact associations. Thought content was negative for any homicidal ideation, suicidal ideation, or psychotic symptoms. Insight and judgment were fair. The examiner rendered a diagnosis of major depressive disorder, recurrent, in remission, and assigned a GAF score fo 60. At a June 2009 VA outpatient visit, the Veteran was noted to feel much better mood wise with mild paranoia. He continued to work at the prison. He also continued to exhibit excessive worry and preoccupation with the mundane. He was not hopeless or suicidal. Mental status examination revealed he was not floridly psychotic but he had residual paranoia. A diagnosis of major depressive disorder with psychosis was rendered. The examiner assigned a GAF score of 60. The Veteran was again noted to not be floridly psychotic at the time of a March 2010 VA outpatient visit, but to still have residual paranoia. A diagnosis of major depressive disorder was again rendered with a GAF score of 60 again being assigned. At the time of a March 2010 VA examination, the Veteran was noted to suffer from a daily depressed mood and severe daily insomnia. He had had fleeting suicidal ideations and daily feelings of worthlessness. The Veteran also reported having fatigue, daily lack of concentration, and daily anxiety. Mental status examination revealed he was clean and had unremarkable psychomotor activity. He was cooperative towards the examiner and had a normal affect. His mood was depressed and he had a short attention span. He was oriented to time, person, and place. Thought process and content were unremarkable. There were no delusions, and as to judgment, the Veteran understood the outcome of behavior. As to insight, he understood that he had a problem. The Veteran only slept two hours per night due to nightmares. His lack of sleep contributed to his drowsiness, moodiness, lack of concentration, and memory loss. The Veteran noted having auditory hallucinations but they were not persistent. As to inappropriate behavior, the Veteran reported having road rage and arguing with people for no reason. As to obsessive/ritualistic behavior, the Veteran stated that he checked the door several times per day and night and he thought he heard someone outside. The Veteran noted having panic attacks twice a month, at which time he had symptoms of sweating, trembling, increased heart rate, kicking in his leg, and difficulty breathing. There was no presence of suicidal or homicidal thoughts. Impulse control was fair, with notations of road rage and destruction of personal property. As to hygiene, the Veteran only bathed three times per week. The Veteran had moderately impaired recent memory. He stated that when he drove he forgot where he was going. The Veteran was noted to work as a prison guard. He had lost six weeks of work in the past 12 months due to back pain and panic attacks. The examiner observed that the Veteran had been assigned to different duties, had decreased concentration, inappropriate behavior, increased tardiness, memory loss, and poor social interaction with others. The Veteran also reported excessive use of force towards inmates and being suspended for hitting a worker, an incident he did not remember. The examiner rendered a diagnosis of recurrent mild major depressive disorder. She assigned a GAF score of 60. She indicated that there was reduced reliability and productivity due to mental disorder symptoms. The examiner noted that the Veteran reported multiple occupational problems including difficulty concentrating and memory loss, which led to him being assigned less stressful duties. Other occasional problems noted were poor social interaction, tardiness, and absenteeism. It was also indicated that the Veteran had reported inappropriate behavior (excessive force with an inmate and hitting a co-worker). At the time of a July 2011 VA outpatient visit, the Veteran was noted to be making only marginal progress with mood dips and difficulties with the work place. He was hopeful and future oriented with no suicidal or homicidal ideation. He was again noted to not be floridly psychotic but to have residual paranoia. The examiner rendered a diagnosis of major depressive disorder with psychosis and assigned a GAF score of 60. At the time of a September 2011 visit, the Veteran was noted to be depressed, markedly irritable, and mildly paranoid. He was still working and complained of his supervisor's lack of support for sick leave. Mental status examination revealed he was not currently psychotic and that he had no suicidal or homicidal ideation. The examiner rendered a diagnosis of major depressive disorder with psychosis and assigned a GAF score of 60. At the time of a March 2012 outpatient visit, the Veteran reported having nightmares, avoidance of events, and irritability. He also noted being hypervigilant. The Veteran remained hopeful and future oriented and denied homicidal and suicidal ideations. Mental status examination revealed he was not currently psychotic and did not have suicidal or homicidal ideations. The examiner noted that the Veteran was employed. The examiner rendered a diagnosis of major depressive disorder with psychosis and questionable PTSD. A GAF score of 60 was assigned. Resolving reasonable doubt in favor of the Veteran, the criteria for a 70 percent disability evaluation for his dysthymic and generalized anxiety disorders have been met throughout the course of the appeal. Since his request for an increased evaluation, the Veteran has been shown to have near continuous depression. Treatment records as early as December 2002 note the Veteran having near continuous depression. Chronic depression was also found to be present at the time of the Veteran's September 2004 VA examination. Long-standing depression was again noted at the time of the Veteran's August 2005 VA examination. Diagnoses of continuous depressive disorder have also been made at the time of numerous VA outpatient visits throughout the course of the appeal. At the August 2007 VA examination it was noted that the Veteran was always somewhat depressed but that he would go into deeper spells of depression, which would last 5 days to two weeks. During those periods of time, he did not want to leave the house or take a bath and he had no energy. The Veteran was also noted to be depressed at the time of his March 2010 VA examination. Depression was also reported in VA outpatient treatment records subsequent to the March 2010 VA examination. Obsessional rituals have also been shown to be present, with it being reported that the Veteran continuously checked locks and washed his hands on several occasions. Impaired impulse control has also been noted throughout the appeal period, with the Veteran continuously reporting problems with his ability to control his anger at work, in form of verbal assaults on co-workers and inmates, and occasional physical encounters with fellow co-workers. He has also reported having at least one incident of road rage during this time period. Neglect of personal hygiene has also been shown, as the Veteran indicated that he did not maintain proper hygiene when in his deeper states of depression. The Veteran has also reported having panic attacks one or two times per month, which would most likely be at a higher rate if he did not tend to isolate himself and avoid crowds as much as possible. His psychiatric symptoms have also interfered with his ability to establish and maintain effective relationships with his co-workers and the inmates which he guards. In sum, the criteria for a 70 percent disability evaluation for the Veteran's service-connected dysthymic and generalized anxiety disorders have been met throughout the course of the appeal. The criteria for a 100 percent disability evaluation have not been met at anytime during the appeal period. The Veteran's dysthymic and anxiety disorders have not been shown to cause total occupational and social impairment. The Board notes that the Veteran has reported having auditory hallucinations at various times throughout the course of the appeal. He has also been noted to have had various encounters with inmates and co-workers and to have had at least one incident of road rage. The Board further observes, as noted above, that the Veteran has problems with personal hygiene during his periods of deeper depression. However, the above symptoms have not been shown to cause or approximate total social or occupational impairment. The Veteran continues to maintain employment as a guard at the prison. While he has been assigned different tasks to perform and he has been shown to miss anywhere from 15-20 days during a six month period, he still maintains full-time employment. Moreover, while his dysthymic and anxiety disorders have impacted his ability to maintain and establish effective relationships with his co-workers, the Veteran is still married to his wife and maintains a relationship with her. Furthermore, although the Veteran has reported auditory hallucinations throughout the course of his appeal, they do not occur on a daily basis. In addition, while the Veteran has been verbally abusive to his co-workers and the inmates, he is aware of his problem and has developed certain coping mechanisms, which prevent this from occurring on a persistent basis. Further, the GAF scores assigned throughout the appeal period, in the 51-60 range, reflect moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Veteran has also not been shown to have symptoms such as disorientation to time or place; memory loss for names of close relatives, own occupation, or own name or gross impairment in thought processes or communication. As such, the criteria for a 100 percent disability evaluation for dysthymic and anxiety disorders have not been met or approximated. Right Shoulder Diagnostic Code 5200 rates ankylosis of the scapulohumeral joint. Where arm limitation of motion is limited to 25 degrees from the side, a 40 percent evaluation is assigned for the major side, and 30 percent is assigned for the minor side. Limitation of motion midway between the side and shoulder level contemplates a 30 percent and 20 percent evaluation for the major and minor sides, respectively; while limitation of motion at shoulder level contemplates a 20 percent evaluation. Diagnostic Code 5201. Under Diagnostic Code 5202, for impairment of the humerus in the major arm, a 20 percent rating is granted when there is malunion, with moderate deformity, for the minor arm, it is also 20 percent; a 30 percent rating is granted when there is marked deformity for the major arm and 20 percent for the minor. Also under Diagnostic Code 5202, for recurrent dislocations of the major and minor arms at the scapulohumeral joint, a 20 percent rating is granted with infrequent episodes, and guarding of movement only at shoulder level; a 30 percent rating is granted when there are frequent episodes and guarding of all arm movements for the major arm and 20 percent for the minor arm. A 50 percent rating is granted for fibrous union of the major arm and 40 percent for the minor arm; a 60 percent rating is granted for nonunion (false flail joint) of the major arm and 50 percent for the minor arm; and an 80 percent rating is granted for loss of head of (flail shoulder) for the major arm and 70 percent for the minor arm. Under Diagnostic Code 5203, for impairment of the clavicle or scapula in the major or minor arm, a 10 percent rating is granted for malunion or nonunion without loose movement; a 20 percent rating is granted for nonunion with loose movement or for dislocation. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion, and a part which becomes disabled on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is to be considered in evaluating the degree of disability, but a little-used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as at least minimally compensable. See also DeLuca v. Brown, 8 Vet. App. 202 (1995) (indicates that pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain may be the basis for a rating for a disability rated based on limitation of motion, regardless of whether or not the limitation of motion specified in the Diagnostic Code criteria is shown). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. 38 C.F.R. § 4.59. At the time of an October 2002 VA examination, the Veteran was noted to be right-handed. He stated that his right shoulder ached during overhead activities or upon abducting or doing forward flexion beginning at the horizontal level to 180 degrees. He indicated that he could not sleep on his shoulder. He avoided overhead work but if he did it, it would cause a flare-up that was moderate in intensity and short-lived. The Veteran was noted to be a prison guard and did not use his right shoulder for overhead activities. Range of motion was normal with forward flexion from 0 to 180 degrees; extension from 0 to 50 degrees; and internal and external rotation from 0 to 90 degrees. There was pain on forward flexion and abduction from 90-180 degrees and pain on external rotation beginning at 45 degrees and ending at 90 degrees. Joint function was additionally limited by pain and decreased endurance following repetitive use or during flare-ups. There was no edema, effusion, instability, or weakness. There was mild tenderness over the A/C joint area as well as the subacromial. There was no abnormal movement or guarding of movement. Shoulder x-rays revealed no bone or joint or soft tissue abnormality, with normal joints. At the time of a September 2004 VA examination, the Veteran again reported having pain when doing overhead activities, with the pain beginning at 90 degrees during abduction or forward flexion. There was no locking or giving way but there was decreased endurance and fatigability upon performing range of motion testing. There was no tingling or numbness. Intensity was noted as 7 out of 10 when pain was present, and the pain subsided when stopping the precipitating activity with temporary decrease in range of motion and of joint function during that activity. There was no additional limitation of motion with repetitive motion. There were no episodes of dislocation or recurrent subluxation. There was also no effect on activities of daily living or occupation except for overhead activities, which the Veteran avoided. Forward flexion was to 180 degrees, external and internal rotation was from 0 to 90 degrees, abduction was from 0 to 180 degrees, and adduction was from 0 to 50 degrees. Pain began at 90 degrees for forward flexion and abduction. There was no shoulder tenderness. There was noted to be a decrease in range of motion after repetitive movement only with forward flexion and abduction. X-rays were normal. The examiner stated that the pain on shoulders was really pain and tenderness over the nape of the neck and the trapezius muscles, aggravated by sneezing. During an August 2005 VA examination there was no history of weakness, swelling, heat, redness, or instability noted. During flare-ups the Veteran rated his shoulder pain as an 8 on a scale from 1 to 10. Precipitating factors included repetitive use, pushing, pulling, lifting heavy articles, and reaching above the head. Alleviating factors were rest and medication. The Veteran was noted to have a temporary limitation of motion during a flare-up. Physical examination revealed forward flexion to 150 out of 180 degrees, internal rotation to 80 out of 90 degrees, external rotation to 60 out of 90 degrees, and abduction to 90 out of 180 degrees. There was no painful motion. Joint function was noted to be additionally limited by 10 degrees in abduction due to pain, stiffness, and lack of endurance following repetitive use. There was no ankylosis. X-rays of the shoulder were normal. A diagnosis of bicipital tendonitis of the right shoulder was rendered. At an August 2007 VA examination, the Veteran reported having constant anterior right shoulder pain, which was non-radiating, with stiffness. He rated the pain at rest as 8/9-10. The Veteran did not have any episodes of dislocation or recurrent subluxation. The condition did not impair his daily functional activities. The Veteran stated that he had missed 30-35 days of work due to this condition in the past six months. Physical examination revealed no edema, ecchymosis, or erythema. The right shoulder was symmetrical to the left shoulder. The shoulder was non-tender with negative acromioclavicular joint tenderness, negative drop arm, and negative apprehension sign. Deltoid contour was present. The shoulder was neurovascularly intact without atrophy. Range of motion revealed flexion to 90 out of 180 degrees, extension to 50 out of 50 degrees, adduction to 30 out of 50 degrees, and internal and external rotation to 90 out of 90 degrees. The Veteran had increase in pain from start to finish in all ranges of motion. He was noted to have increased ranges of motion when dressing and during passive ranges of motion. He also displayed signs of non-organic symptoms with superficial anatomical pain. No additional limitations of motion were noted after 3 repetitions related to pain, fatigue, incoordination, weakness, or lack of endurance. The examiner rendered a diagnosis of right shoulder bursitis with residuals. It was observed that the subjective complaints far outweighed the objective findings on examination. As his July 2008 Travel Board hearing, the Veteran testified that he had to stop raising his arm somewhere between his side and shoulder length. He indicated that he could lift a little less than halfway. He stated that his shoulder pain started as soon as he moved his arm. The Veteran's wife testified that the Veteran had right shoulder pain all the time. At the time of a March 2010 VA examination, the Veteran reported that his shoulder pain was 7-8/10 with associated stiffness. There was no specific deformity or instability. Locking was not present and there was no dislocation, subluxation, or effusion. Tenderness was present in the right shoulder diffusely in the shoulder girdle. There were no signs of swelling, heat, redness, or drainage. Flare-ups were noted to occur with repetitive movements of the right shoulder. This was proportionate to usage. The flare-ups lasted for about one hour. Precipitating factors were increased usage. Alleviating factors were rest and to a certain extent medication. There was no permanent functional impairment with additional limitations. The Veteran was noted to work for the Department of Criminal Justice. The Veteran stated that in the past year he had missed three to four weeks of work because of the right shoulder condition. His day-to-day activities were noted to be self-sufficient. Physical examination revealed diffuse tenderness on the right shoulder, posteriorly, anteriorly, and superiorly. Forward flexion and abduction were from 0 to 90 degrees. The Veteran did not perform external and internal rotation due to the severity of the pain. There was no expression of pain at rest; however, with active range of motion and end range of motion with flexion and abduction, there was expression of pain. There was no edema, effusion, or instability. There was also no heat, redness, or abnormal movement. Guarding of movement was present. There was also no deformity, malalignment, drainage, or weakness. There was also no ankylosis. The examiner stated that there was continued pain with repetitive use of three times; however, there was no additional limitation of motion and no change in range of motion. X-rays for the right shoulder were reported as normal. As to whether an evaluation in excess of 20 percent is warranted for the right shoulder, the Board notes that there have been no reports or findings that the Veteran's right shoulder range of motion has been limited to midway between the side and shoulder level or to 25 degrees from the side. As such, an increased rating for this period is therefore not warranted under Diagnostic Code 5201. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. Here, the Board notes the Veteran's reported impairment of function, such as not being able to lift heavy objects, and having difficulty with push and pulling, and being unable to lift his arm over his head and has considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in). While the Board notes that pain on flexion and abduction was noted on numerous examinations, there was no demonstration of limitation to less than midway between the side and shoulder level at any time, even following repetitive motion. The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain. The Board finds the criteria for a rating in excess of 20 percent for right shoulder disability have not been met or more nearly approximated for any period of the increased rating claim. Because the weight of the evidence shows that the Veteran's service-connected right shoulder disability did not manifest limitation of motion midway between the side and shoulder level; and did not manifest malunion, fibrous union, nonunion, or ankylosis of the right shoulder at any time during the increased rating period, an increased rating in excess of 20 percent is not warranted for any period. 38 C.F.R. § 4.71a, DCs 5200-5203. For these reasons, the Board finds that the weight of the evidence is against a finding of an increased rating in excess of 20 percent for right shoulder bursitis. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R.§ 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's dysthymic and generalized anxiety disorders is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DCs 9433-9400, specifically provide for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's dysthymic and generalized anxiety disorders manifested symptoms which were either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. The Veteran's right shoulder bursitis corresponds to the schedular criteria for the assigned disability evaluation, which also incorporates various orthopedic factors that limit motion or function. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. For this reason, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's right shoulder bursitis and no referral for an extraschedular rating is required. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "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." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the acquired psychiatric disorder or the right shoulder bursitis, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the Veteran is employed. Consequently, the matter of entitlement to a total disability rating based on individual unemployability is not raised by the Veteran or the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A 70 percent evaluation, and no more, for dysthymic and generalized anxiety disorders, is granted. An evaluation in excess of 20 percent for right shoulder bursitis is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs