Citation Nr: 1306443 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 99-00 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to a higher initial rating for generalized anxiety disorder prior to November 3, 2004, currently rated 30 percent disabling. WITNESSES AT HEARING ON APPEAL The Veteran and J.J. ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from April to November 1974. He also had 5 months and 21 days of prior active service. This matter initially came before the Board of Veterans' Appeals (Board) from a May 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In that decision, the RO granted service connection for anxiety disorder and assigned an initial 30 percent disability rating, effective January 28, 1994. In January 1999, the Veteran testified at a hearing before a local hearing officer at the RO and a transcript of that hearing has been associated with his claims folder. In May 2000, the Board denied the appeal for an initial rating higher than 30 percent for generalized anxiety disorder. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In April 2001, the Court vacated the Board's May 2000 decision and remanded the case for readjudication in compliance with directives specified in a February 2001 Motion filed by VA's General Counsel. In October 2001, the Board remanded this matter for further development in compliance with the February 2001 Motion. In August 2002, the Board again denied the appeal for an initial rating higher than 30 percent for generalized anxiety disorder. The Veteran appealed the Board's denial to the Court. In July 2003, the Court vacated the Board's August 2002 decision and remanded the case for readjudication in compliance with directives specified in a July 2003 Joint Motion filed by the Veteran's representative and VA's General Counsel. In April 2004, the Board remanded this matter for further development in compliance with the Joint Motion. In October 2005, the RO assigned an initial 50 percent rating for generalized anxiety disorder, effective November 3, 2004. In December 2006, the Board denied the appeal for a higher initial rating for generalized anxiety disorder. The Veteran again appealed the Board's denial to the Court. In a December 2008 memorandum decision, the Court vacated the Board's December 2006 decision and remanded the case for readjudication in compliance with directives specified in the Court's decision. In July 2009, the Board remanded this matter for further development in compliance with the Court's decision. In May 2011, the Board granted an initial 100 percent rating for generalized anxiety disorder, effective November 3, 2004. The Board remanded the issue of entitlement to an initial rating higher than 30 percent for generalized anxiety disorder prior to November 3, 2004 for further development. The Veteran was previously represented by a private attorney. In June 2009, the Veteran and his representative expressed their intent to have such representation revoked. In July 2009, a Veterans Law Judge granted the motion for such representation to be withdrawn. The Veteran is now unrepresented. 38 C.F.R. § 20.608(a) (2012). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. The documents in this file have been reviewed and are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. FINDING OF FACT From January 28, 1994 through November 2, 2004, the Veteran's generalized anxiety disorder was manifested by a demonstrable inability to obtain or retain employment. CONCLUSION OF LAW The criteria for an initial 100 percent rating for generalized anxiety disorder, from January 28, 1994 through November 2, 2004, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9400 (2012); 38 C.F.R. § 4.132, DC 9400 (1994). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 as amended (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. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). As the Board is granting the highest rating possible for generalized anxiety disorder for the entire appeal period, the claim is substantiated, and there are no further VCAA duties. Wensch v. Principi, 15 Vet App 362, 367-68 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). Disability evaluations are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002). Where service connection has been granted and the assignment of an initial evaluation is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). 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 (2012). 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). 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 (2012). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. §§ 4.125, 4.130 (2012). The criteria for rating generalized anxiety disorder were changed during the course of the Veteran's claim on November 7, 1996. See 61 Fed. Reg. 52700 (Oct. 8, 1996). VA's General Counsel has held that where a law or regulation changes during the pendency of an appeal, the Board should first determine which version of the law or regulation is more favorable to the Veteran. If the application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation. 38 U.S.C.A. § 5110(g) (West 2002). Prior to the effective date of the change in the regulation, the Board can apply only the original version of the regulation. VAOPGCPREC 3-2000 (Apr. 10, 2000). A new law or regulation applies, if at all, only to the period beginning with the effective date of the new law or regulation. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has created a three-part test to determine whether a new law has prohibited retroactive effects: (1) "the nature and extent of the change of the law"; (2) "the degree of connection between the operation of the new rule and a relevant past event"; and (3) "familiar considerations of fair notice, reasonable reliance, and settled expectations." Princess Cruises v. United States, 397 F.3d 1358 (2005). If, under this test, a rule or regulation appears to have a retroactive effect, then the rule or regulation cannot be applied to cases pending at the time of its promulgation. Rodriquez v. Peake, 511 F.3d 1147 (2008). Under the old criteria for rating generalized anxiety disorder, a 30 percent disability rating is warranted when there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people. The psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. 38 C.F.R. § 4.132, DC 9400 (1994). A 50 percent disability rating is warranted when the ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. Id. A 70 percent disability rating is warranted when the ability to establish and maintain effective or favorable relationships with people is severely impaired. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. Id. A 100 percent disability rating is warranted if the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community; there are totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior; or where the generalized anxiety disorder results in a demonstrable inability to obtain or retain employment. Id. The former criteria for a 100 percent rating are separate and independent bases for granting a 100 percent rating. 38 C.F.R. § 4.132, DC 9400; see Johnson v. Brown, 7 Vet. App. 95, 97 (1994). Effective November 7, 1996, generalized anxiety disorder is rated under 38 C.F.R. § 4.130, DC 9400, according to the General Rating Formula for Mental Disorders. Under the General Rating Formula, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9400 (2012). A 50 percent disability rating is warranted when there is 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances ( including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted when there is 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; and memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The Board has considered the Global Assessment of Functioning (GAF) scores assigned during the appeal period. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DSM-IV at 32). GAF scores ranging from 11 to 20 reflect behavior that results in some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). GAF scores ranging from 21 to 30 reflect behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or an inability to function in almost all areas (e.g. stays in bed all day; no job, home, or friends). GAF 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). GAF 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). GAF scores ranging from 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. Also, GAF scores ranging from 71 to 80 reflect symptoms which, if present, are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) and cause no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind on schoolwork). Id. However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Because a new law or regulation applies, if at all, only to the period beginning with the effective date of the new law or regulation, only the old criteria for rating generalized anxiety disorder may be applied prior to November 7, 1996. Kuzma, 341 F.3d at 1327. An October 1975 "Veteran's Application for Compensation or Pension" form (VA Form 21-526), a June 1978 "Income-Net Worth and Employment Statement" (VA Form 21-527), a June 1976 VA treatment record, a November 1978 VA examination report, and statements from the Veteran dated in August 1977 and June 1979 reflect that he had a high school education and that he had reportedly been fired from jobs due to worsening problems with his nerves, back, and episodes of loss of consciousness. He reported during the June 1976 VA evaluation that he had quit a job loading and unloading trucks approximately 2 months prior to the evaluation, apparently due to the fact that he had been insulted and provoked by others. However, he reported on the June 1978 VA Form 21-527 that he had last worked in 1972 during his active duty service and that any attempts at employment since that time had been unsuccessful. Also, during the November 1978 VA examination he reported that he had injured his back at work in 1976 and that he had been unable to work since that time. Overall, he contended that he had been unable to work or study since service and that he was totally and permanently disabled since that time due to service related disabilities, including his psychiatric disability. In a letter dated in February 1980, a former employer of the Veteran reported that the Veteran had worked as a refrigeration mechanic both before and after service. Prior to service, he had always been very polite, kind, friendly, and extroverted with his coworkers. However, when he was re-hired following service, he was frequently absent from work due to mood changes. He "did not accept jokes" from coworkers and engaged in fistfights with them on several occasions. A report of a VA field examination dated in March 1980 indicates that the Veteran's family members reported that the only employment attempted by the Veteran following service was in a warehouse. He had been fired due to his "wild attitude toward his workmates" (e.g. he often engaged in fights with his coworkers). Also, he did not observe his duty hours and often quit after only a few hours of work. The VA field examiner who conducted the evaluation concluded that he had "no doubts of the honesty of the people interviewed." However, the Veteran's nerves did not "look that bad" and the examiner did not feel that he was totally disabled due to his psychiatric disability. Nevertheless, he had not been able to engage in any gainful occupation since his employment at the warehouse had ended following service. During a May 1983 psychiatric evaluation at the Psychiatric Center of Puerto Rico the Veteran reported that he had left his job as a refrigeration technician due to frequent memory loss, headaches, and insomnia. Disability records from the Social Security Administration (SSA) reflect that the Veteran had employment experience as a bar tender, operator of a cigar company, salesman, welder, and refrigeration mechanic. He was reportedly unable to continue working due to headaches, memory problems, and an employment-related back injury. A "Cessation or Continuance of Disability or Blindness Determination and Transmittal" form from the SSA dated in June 1983 indicates that the Veteran's disability began in June 1976 and that it was determined to be continuing. The primary diagnosis was noted to be paranoid schizophrenia. VA treatment records dated from October 1989 to May 1994 include reports of sleep difficulties, nervousness, nightmares, anxiety, chronic depression, irritability, auditory hallucinations, and "self harm ideas." Such symptoms were treated with medications. The Veteran reportedly remained unemployed due to his "nervous condition." A diagnosis of dysthymia was provided. In a January 1994 letter, Félix Maldonado Feliciano, M.D. reported that he had provided ambulatory psychiatric treatment to the Veteran since February 1982, at which time his mental status examination, symptom complex, and behavior were all compatible with a diagnosis of chronic undifferentiated schizophrenia. One of his most dramatic symptoms was a headache of undetermined origin. Further medical and psychiatric studies were needed to determine the etiology of such headaches. Overall, the Veteran's improvement had only been mild and his general prognosis was poor. During a November 1996 VA examination the Veteran reported that he had been unemployed for approximately 15 to 20 years, that he had last worked as a driver/utility man, and that he was in receipt of SSA disability benefits. He had not received any recent VA psychiatric treatment and had not received any psychiatric medications from VA for the previous 6 months. However, he reported that he received private psychiatric treatment. He was married, had 3 children, and experienced restlessness and headaches. Examination revealed that the Veteran was dressed casually and carried himself appropriately. He looked somewhat restless, but there was a very strong, voluntary component. His answers during the examination were vague and superficial, but they were coherent and relevant and he was "in contact." There was no delusional material elicited, no apparent perceptive disorder, and no suicidal rumination. Also, judgment was preserved and the Veteran properly differentiated between right and wrong. Although his memory was difficult to explore, recent memory was intact and was not considered impaired. Overall, there was a predominating anxiety. The Veteran was diagnosed as having anxiety disorder, not otherwise specified (NOS) and a GAF score of 75 was assigned, indicative of slight impairment. A September 1997 VA mental health evaluation report reflects that in the years since service, the Veteran experienced memory problems, headaches, hostility, social isolation, insomnia, problems with his family, and problems with "aimless wandering." He was granted SSA disability benefits in 1976 due to a neuropsychiatric condition. A diagnosis of schizophrenia, undifferentiated type was provided. A report of a VA psychiatric examination dated in October 1997 includes a report that the Veteran's behavior during the examination was observed to be markedly voluntary. For example, when he entered the examination room he began to make multiple gestures reflecting anxiety. He claimed that he did not know the year of his birth, that he could not remember his age, that he was unaware that he had been married twice, that he did not know the identity of his treating psychiatrist, and that he could not remember his prescribed medications. He was vague as to his symptoms and reported only that he felt "bad," he did not feel well, he experienced severe headaches, he could not "remember anything," his mind would go blank, and he did not know what he was doing. He was questioned as to his previous hospitalizations and treatment, but he alleged that he was unable to remember any such details. Examination revealed that the Veteran was casually and adequately dressed and groomed. He "tried to appear" restless and anxious, was completely avoidant of direct eye contact, and exhibited markedly voluntary behavior during the course of the examination. The details of his symptoms were markedly vague and unspecific, but he reported that he was alone and depressed, that he experienced sleep problems, and that he did not know what he was doing most of the time. His affect was inappropriate because it was exaggerated, his mood was restless, his judgment was fair, and his insight was poor. However, there were no hallucinations, delusions, or suicidal/homicidal ideations. The Veteran was oriented in person, but no objective evaluation could be performed due to the strong voluntary component involved. Overall, the psychiatrists who conducted the examination concluded that the Veteran remembered much more than what he cared to express and that his intellectual functioning was maintained. A final opinion as to the severity of the Veteran's disability was delayed pending completion of a VA Social and Industrial Field Survey. A VA Social and Industrial Field Survey was conducted in November 1997. The report of the field survey reflects that the Veteran reportedly had very little involvement with home tasks and that he seldom talked with his neighbors. He was observed to be crying during the interview and he reported that he experienced headaches, depression, and nervousness. He spent his time visiting a relative's farm, visiting his mother, and attending trials at a local court. He had attended vocational school and worked as a refrigeration technician until he was awarded SSA disability benefits in 1976. His wife reported that he was irritable, argumentative, and demanding and that he had problems with his children because he treated them as if they were younger than they actually were and wrongfully disapproved of their friends and girlfriends. He spent most of the day away from home with other family members. However, his neighbors reported that he was cordial and had good relationships with his wife, children, and neighbors. The examiners who conducted the October 1997 VA examination reviewed the results of the November 1997 VA field survey and concluded that the Veteran's behavior during the October 1997 examination was voluntary and manipulative and that the information given to the social worker during the field survey was not confirmed by collateral information. Overall, there was no evidentiary support for a diagnosis of a psychosis. The Veteran had not been receiving regular psychiatric treatment and his only medication was Dalmane. He was diagnosed as having factitious disorder with psychological symptoms (subsequently changed to malingering) and schizophrenia "by history only." A GAF score of 70 to 75 was assigned, indicative of mild to slight impairment. In a June 1998 statement (VA Form 21-4138), an unknown individual reported that the Veteran had been found to be completely unable to engage in any gainful activity since 1976. As a result, he was found by the SSA to be totally unfit to work as of that time. He was completely and severely sick due to his "nervous condition" and it was suggested that his disability be evaluated as 100 percent disabling. His disability was chronic and permanent in nature, improvement was unlikely to occur, and he required indefinite psychiatric treatment. He was unable to handle funds and his prognosis was "very severe." The Veteran reported on a November 1998 "Veteran's Application for Increased Compensation Based on Unemployability" form (VA Form 21-8940) and during the January 1999 hearing that he had a high school education, that he had received training to be a refrigeration technician, and that he had last worked full time in that field in 1978. His "nervous" disability prevented him from securing or following any substantially gainful occupation. The Veteran's private psychiatrist reported during the January 1999 hearing that the Veteran's condition was "significantly deteriorated," that he had no interpersonal relationships, that he was always "locked up" and in a bad mood, that his memory was "at its worst," and that he experienced numerous somatic complaints. His nervous condition was "worse every day" and disabled him completely, he had stopped working due to his emotional problems, and he had been awarded SSA disability benefits for such problems. The psychiatrist opined that the Veteran's disability was deteriorating and that his GAF score at the time of the January 1999 hearing was 20 to 30 (indicative of gross impairment to an inability to function in almost all areas) due to the nature of his symptoms and the problems with his interpersonal relationships. He had been prescribed anti-psychotic medications, but there had been no significant improvement in his condition, despite treatment. In a January 1999 letter, the Veteran's former employer reported that the Veteran had stopped working due to his emotional and physical conditions. Any further employment information was unavailable due to a fire that had taken place in 1980. A February 1999 VA examination report reveals that the Veteran was prescribed psychiatric medications and that he reported that he was unemployed, that he used to work at a furniture store, and that he lived with his wife. His response to all questions was that he did not know the answer and that his wife knew all pertinent information. However, he did report sleep difficulties, headaches, and irritability. He was not precise or descriptive as to his history, symptoms, and complaints. Examination revealed that the Veteran was clean and well developed, but unshaven for a couple of days. He appeared extremely anxious, confused, and restless, but such behavior was clearly voluntary. His affect was constricted, he avoided eye contact, and he had fair attention, concentration, insight, judgment, and impulse control. However, he was alert and fully oriented, his speech was clear and coherent, and there were no hallucinations, thought or perceptual disturbances, or suicidal/homicidal ideations. A diagnosis of generalized anxiety disorder was provided and a GAF score of 75 was assigned, indicative of slight impairment. The medical professional who conducted the February 1999 VA examination opined that based on the Veteran's described behavior in his records, his behavior was an exaggeration of his condition with secondary gain intentions. During a February 2002 VA examination the Veteran reported that he lived with his second wife, that he had 3 adult daughters, that he had a high school education and employment experience as a refrigerator mechanic, driver, and utility man in a warehouse of a furniture store, that he was unemployed at the time of the examination, and that he had been in receipt of SSA disability benefits since 1976 due to schizophrenia and anxiety. He was taking medications for the symptoms of his psychiatric disability. He experienced impaired memory and was unable to tolerate questions. Examination revealed that the Veteran was dressed with moderate care and had an unshaved beard and uncombed hair. He appeared older than his chronological age, but was alert and in no acute distress. He avoided eye contact with the examiners throughout the examination and was initially withdrawn. He subsequently became uneasy and anxious during the examination. He was able to understand the purpose of the examination, but his answers were vague and evasive and he complained in a hesitant, soft voice that he had problems with his memory. His answers were approximate and inaccurate (e.g. he was unable to remember his age, the place of his birth, or the age and address of his mother). At one point during the examination he suddenly screamed in a high pitched voice and stated that he did not feel comfortable with the questions being asked. He then rested his head on the examiner's desk and accepted the fact that he was unable to continue the examination. His wife was contacted in the waiting room and she was able to comfort and calm the Veteran. Moreover, the Veteran reported memory problems and his insight and judgment were found to be fair. However, he was in full contact with reality throughout the examination, there was no evidence of any destructive or aggressive behavior or a thought disorder, and he was coherent, relevant, and logical throughout the examination. There was no evidence of any active disorder of perception. The Veteran was unable to cooperate with the evaluation of cognitive and sensorium functions. He was diagnosed as having general anxiety disorder, chronic undifferentiated schizophrenia "by record," and depression NOS "by record." A GAF score of 55 was assigned, indicative of moderate impairment. The examiners who conducted the examination noted that they concurred with the psychiatric diagnostic impression provided by the examiners who had conducted the October 1997 VA psychiatric examination. A September 2002 report of a psychiatric examination conducted for SSA purposes reflects that the Veteran appeared to be absent-minded, that he was isolated and forgetful, that he had problems with his neighbors and relatives, and that he aimlessly wandered his neighborhood. He was reportedly unable to cope with his family situation. Examination revealed that he was fully oriented. However, he was loose in his ideation, there was "blocking," his affect/mood was inappropriate and depressed, his memory was fair to poor, his attention span, judgment, and impulse control were all poor, and his concentration was impaired. He did not engage in any activities at home or any social functioning and he was unable to cope with any stressful situations or persist on any tasks. Overall, the psychiatrist who conducted the evaluation concluded that the Veteran's physical and mental conditions were chronic and rendered him unable to work. He was diagnosed as having severe undifferentiated schizophrenia, a GAF score of 30 to 40 was assigned (indicative of an inability to function in almost all areas to major impairment), and his prognosis was described as being "very very poor." VA treatment records dated from September 2003 to September 2004 include reports of visual and auditory hallucinations, paranoia, anxiety, and occasional social isolation. However, the Veteran's relationships with his family had reportedly improved. Examinations revealed that he was alert, oriented, and cooperative. His affect was blunted (but brightened on approach) and he was slightly anxious. However, he was not suicidal, homicidal, or psychotic and his mood, insight, and judgment were all good. Diagnoses of generalized anxiety disorder, psychotic disorder NOS, and depression NOS were provided and a GAF score of 55 was assigned, indicative of moderate impairment. A report of a VA psychiatric examination dated in November 2004 reveals that the Veteran had received VA outpatient psychiatric treatment during the previous year and that during that time, diagnoses of generalized anxiety disorder and psychotic disorder NOS were provided and a GAF score of 50 was assigned, indicative of serious impairment. He had stopped working in 1976 due to his psychiatric disability and was receiving SSA disability benefits. He lived with his second wife and two sons, but reported impaired relationships with his wife and children due to irritability and anxiety. Additionally, he reported anxiety, restlessness, tension, insomnia, impaired concentration, irritability, sadness, and depression. Such symptoms had been present during the previous year. Also, he did not like to be in groups or crowds (e.g. avoided shopping centers), did not like to be in closed spaces (e.g. did not like to be alone in elevators), and experienced anxiety episodes for no apparent reasons. Examination revealed that the Veteran was appropriately dressed, had adequate hygiene, and was cooperative. He was spontaneous, established eye contact with the examiner, was alert and in contact with reality, and did not exhibit any psychomotor retardation or agitation, tics, tremors, or other abnormal involuntary movements. His thought process was coherent and logical, his memory was intact, his abstraction capacity was normal, there was no looseness of association or disorganized speech, and there was no evidence of delusions, hallucinations, obsessions, or suicidal ideas. Also, there was no evidence of inappropriate behavior and the Veteran was able to maintain basic activities of daily living. However, his mood was anxious and depressed, his affect was constricted and appropriate, and his insight, judgment, and concentration were all fair. Overall, his psychiatric signs and symptoms seriously interfered with his employment and social functioning. The Veteran was diagnosed as having generalized anxiety disorder and a GAF score of 50 was assigned, indicative of serious impairment. The medical professionals who conducted the November 2004 VA examination opined that the Veteran's generalized anxiety disorder resulted in serious symptoms and serious impairment in social and occupational functioning which interfered with his industrial capacity and his ability to tolerate the demands and daily stressful situations of a working environment. Thus, he was unable to maintain or adequately perform a continuous job. During a September 2009 VA examination, the Veteran reported that for a "long time," he had experienced intense anxiety, restlessness, tenseness, impaired sleep, irritability, and loss of motivation on a daily basis. Examination revealed that his psychomotor activity was restless, his attitude was guarded, his mood was anxious and restless, his attention, orientation to time, and memory were all impaired, and his thought process was impaired by blocking. He did not like to be in crowds and his psychiatric symptoms caused slight to severe impairment with some activities of daily living and prevented other activities of daily living. The Veteran was diagnosed as having generalized anxiety disorder and a GAF score of 45 was assigned, indicative of serious impairment. The psychiatrist who conducted the September 2009 VA examination concluded that the Veteran's psychiatric disability was severe, that he was unable to maintain gainful employment due to the disability, and that there was total occupational and social impairment due to his psychiatric symptoms. The evidence reflected that his anxiety symptomatology had been present "since active service" and the longitudinal medical evidence suggested a continuity of neuropsychiatric symptomatology, including chronic anxiety, restlessness, impaired concentration, irritability, tension, and sleep impairment. Initially, the Board notes that the Veteran had been diagnosed as having non service-connected psychiatric disabilities other than generalized anxiety disorder during the appeal period prior to November 3, 2004, including dysthymia, schizophrenia, psychotic disorder NOS, and depression NOS. However, where an examiner is unable to distinguish the symptoms of a service-connected disability from non-service connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). In this case, there is no evidence to clearly distinguish the symptoms of the Veteran's service-connected generalized anxiety disorder from his other diagnosed non service-connected psychiatric disabilities. Thus, the Board will attribute all of the Veteran's psychiatric symptoms to generalized anxiety disorder for the purposes of assessing the severity of that disability. Id. The evidence reveals that the Veteran has been continuously unemployed since the effective date of service connection for generalized anxiety disorder and that he has consistently reported an inability to work due to his psychiatric disability. The Board acknowledges that he has provided some inconsistent statements concerning the nature and history of his employment as well as the nature of his psychiatric symptomatology calling into question his credibility. Also, several GAF scores have been assigned indicative of only mild to slight impairment and various VA medical professionals have concluded that the Veteran's reported symptoms were exaggerated. For example, the examiners who conducted the October 1997 VA examination reported that the Veteran's demonstrated symptoms were voluntary and manipulative and they provided a diagnosis of malingering. Also, the examiner who conducted the February 1999 VA examination reported that the Veteran's behavior was an exaggeration of his condition and that there were secondary gain intentions. Nevertheless, former employers of the Veteran have reported that he had experienced emotional and behavioral problems at work, and the most recent letter from a former employer dated in January 1999 reflects that he had stopped working due, at least in part, to his emotional problems. His private treatment provider testified during the January 1999 hearing that his psychiatric disability was severe and rendered him totally disabled, and he has been in receipt of SSA disability benefits since 1976 for a psychiatric disability. The examiners who conducted the November 2004 VA examination concluded that the Veteran was unable to maintain or adequately perform a continuous job due to his service-connected generalized anxiety disorder. This opinion was based on psychiatric symptoms which had been present during the course of the previous year and which resulted in serious impairment in occupational functioning and interference with the Veteran's industrial capacity and his ability to tolerate the demands and daily stressful situations of a working environment. Moreover, the examiner who conducted the September 2009 VA examination concluded that the Veteran's psychiatric disability was severe, that he was unable to maintain gainful employment due to the disability, and that there was total occupational and social impairment due to his psychiatric symptoms. This opinion was based on psychiatric symptomatology which had been present since service. In sum, the evidence is in at least equipoise that the Veteran's generalized anxiety disorder resulted in a demonstrable inability to obtain or retain employment from the date of service connection through November 2, 2004. Such occupational impairment most closely approximates the criteria for a 100 percent rating under the criteria in effect prior to November 7, 1996. See 38 C.F.R. § 4.132, DC 9400 (1994). This is particularly so when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The old rating criteria is applicable to the entire rating period on appeal. Hence, an initial 100 percent rating is warranted for the entire period from January 28, 1994 through November 2, 2004 and the full benefit sought on appeal is granted. ORDER An initial 100 percent rating for generalized anxiety disorder, from January 28, 1994 through November 2, 2004, is granted, subject to the law and regulations governing the payment of VA monetary benefits. ____________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs