Citation Nr: 1307728 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 07-05 241 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an increased rating, in excess of 30 percent, for adjustment disorder with chronic anxiety (hereinafter psychiatric disability). 2. Entitlement to a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Allen Gumpenberger, Agent ATTORNEY FOR THE BOARD C. Fields, Associate Counsel INTRODUCTION The Veteran had active service from June 1966 to March 1970. These matters are before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision that denied an increased rating for adjustment disorder with chronic anxiety and from a March 2010 rating decision that denied entitlement to TDIU. These decisions were issued by the Hartford (Newington), Connecticut Department of Veterans Affairs (VA) Regional Office (RO). The Veteran initially requested a formal hearing before a Decision Review Officer (DRO) at the RO. However, he later attended an informal conference in lieu of a hearing. The conference report is of record. No Board hearing was requested. The Board remanded these issues for further development in October 2012. As discussed below, the directives were not completed as to the claim for a TDIU, and this issue must again be remanded. See Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the Veteran if any action on his part is required. FINDINGS OF FACT The Veteran's psychiatric disability results in mild to moderate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although with generally satisfactory functioning, routine behavior, self-care and normal conversation, due to symptoms including chronic sleep impairment, depressed mood, anxiety or nervousness, suspiciousness, anger and irritability, mild memory loss or concentration difficulties, and some relationship difficulties, requiring medication management, most nearly approximating the criteria for a 30 percent rating. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for adjustment disorder with chronic anxiety have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9413-9440 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided to a claimant prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). In this case, the Veteran was advised in March 2008 of the evidence and information necessary to substantiate his claim (i.e., evidence that his psychiatric disability has increased in severity) and the responsibilities of the Veteran and VA in obtaining such evidence. He was also advised at that time of the evidence and information necessary to establish a disability rating and an effective date. No further development is required with respect to the duty to notify. With regard to the duty to assist, all pertinent, available medical records have been obtained and considered. The paper claims file includes Vet Center records dated through 2008 and VA treatment records dated through July 2011 and in September 2012. The Virtual VA file (a highly secured electronic storage system) contains VA records dated from February 2011 through June 2012. There are no additional pertinent records after the last supplemental statement of the case. The Veteran began receiving benefits from the Social Security Administration in December 2010; however, such benefits are not for disability and are not pertinent to the appeal. The Veteran has not identified, and the record does not otherwise indicate, any outstanding medical records that are necessary to decide his claim. Although there is an indication that the Veteran continued to receive counseling at the Vet Center after 2008, he has not authorized VA to obtain such non-VA records. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (VA's duty to assist in developing the pertinent facts and evidence in connection with a claim is not a one-way street, and the claimant has a responsibility to cooperate in such development). Moreover, there is no indication that such records would contain further evidence in support of his claim. Rather, the Veteran's lay descriptions of the severity of his psychiatric disability have been generally consistent throughout the appeal, and there are pertinent medical records (including treatment records and VA examinations) spanning the period on appeal. There is no indication, and the Veteran has not claimed that the Vet Center records would show other symptoms or severity. As such, the Veteran is not prejudiced by their absence. The Veteran was also afforded VA examinations in October 2009, August 2011, and November 2012 (as directed in the prior remand) in connection with his claim. The examiners measured and recorded the subjective and objective mental health symptoms and addressed the degree of social and occupational impairment. Further, the most recent examination report is in compliance with the prior remand. The evidence is deemed sufficient for a fair adjudication. As discussed above, the prior remand directives were accomplished. Further, under the circumstances of this case, another remand would serve no useful purpose, as it would unnecessarily impose additional burdens on VA with no benefit to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA has satisfied its duties to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceedings. As such, the Veteran will not be prejudiced by a decision on the merits of this claim at this time. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings must be considered and should be assigned when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence of record that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. Under 38 C.F.R. § 4.130, all service-connected mental health disabilities are rated pursuant to the General Rating Formula for Mental Disorders. For a 30 percent rating, the evidence must show: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), 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). For a 50 percent rating, the evidence must show: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. To warrant a 70 percent rating, the evidence must show: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. To achieve a 100 percent rating, the evidence must show: 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 Code (DC) 9413-9440. The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list but, rather, serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating for a mental disorder. In addition to the symptoms listed in the rating schedule, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The DSM-IV provides for a global assessment of functioning (GAF), a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DSM-IV). In this case, the Veteran's psychiatric disability has been rated as 30 percent disabling since 2005. He filed a claim for a higher rating in February 2008. He retired from his long-term position as a mail carrier in December 2009, at age 63. The Veteran and his representative contend that although his retirement was voluntary, he made the decision in large part because he had persistent mental health symptoms including problems getting along with others. The Veteran's representative argues that, although the Veteran's symptoms may appear better since he stopped working, VA should consider how he would act under the ordinary conditions of life including employment. The Veteran seeks a rating of at least 50 percent due to symptoms including depression, anxiety, anger and irritability, chronic sleep impairment, mild memory loss or concentration difficulties, relationship difficulties, and GAF scores suggesting moderate impairment. See, e.g., March 2010 letter from Veteran; January 2013 arguments from representative. The Veteran asserted in his February 2008 claim that his mental health symptoms were getting worse. In a September 2008 statement, he indicated that he had no hobbies or recreational pursuits other than working in his garden and in the yard with his wife, and the keeps to himself and his family. In a May 2009 statement, he asserted that his symptoms had become worse over the past few months. In a December 2009 notice of disagreement, the Veteran that he was unable to work due to his anxiety, and he had quit because he simply could not go back. In a March 2010 letter, the Veteran reported that his problems with depression, sleep, and anger issues become more prominent when he developed and was treated for prostate cancer, or in 2001. He also stated that his thoughts of combat experiences have become more intense with age. The Veteran stated that he retired in December 2009 because he could not cope anymore due to stress and depression. Similarly, in a December 2009 letter, the Veteran's wife indicated that he began to have noticeable problems around 2005, when he started receiving VA mental health treatment and counseling after being treated for prostate cancer. He was difficult to live with due to short temper and mood swings, which had increased with age. The Veteran also had chronic sleep impairment, checked the doors at night, and was agitated by news about current wars. The Veteran's wife stated that he used to like his job and have pride in it, but he had begun leaving early and saying he was sick. The Veteran starting receiving counseling at the Vet Center in 2005, and he has received mental health therapy and medications from the VA hospital since 2009. Shortly after the Veteran filed his claim, in a March 2008 letter, a Vet Center counselor summarized his symptoms and treatment since 2005. The counselor stated that the Veteran had long-term low grade depression from service. He also reported invasive thoughts, survivor guilt, and avoiding conversation about the military and events that may trigger memories. He was noted to have detachment from others and poor concentration. The Veteran was hypervigilant, had enhanced startle response, and difficulty watching some TV programs and movies. This is generally consistent with the Board's review of the Vet Center records. During an October 2008 VA examination, the Veteran reported occasional depression and anxiety, stating that sometimes his heart would begin to pound when he thought about distressing memories from service. He reported sleeping "fairly well" and that he woke up at night due to dreams about service, but he was generally able to fall asleep again quickly. He remained hypervigilant and had occasionally exaggerated startle response. He stated that the used to dislike parades, but he was now involved in a VSO and had been participating in parades with them. The Veteran generally spent his recreational time performing yard work, but he denied any loss of interest in activities and stated that he had also had no other interests in the past. He reported feeling depressed lately with lower energy, negative thoughts, survivor guilt, feeling like he did not accomplish as much in his job as he could have, and prostate problems. His affect was slightly blunted. During the examination, the Veteran stated that his irritability and anger had worsened over the past two years, and he did get angry with his wife and children. However, he still had good relationships with his wife, children and grandchildren, whom he saw frequently. The Veteran and his wife associated with one couple every once in a while. He associated with his co-workers while at work and had good working relationships, but he did not associate with them outside of the workplace. He described his job as "okay" and stated that he planned to retire at age 65. The Veteran reported that his concentration had been "a little lax" lately and he had made mistakes while sorting mail. His memory was grossly intact. A GAF score of 54 was assigned, signifying moderate symptoms. A PTSD checklist during the 2008 examination showed mild to moderate levels of posttraumatic symptoms, and a patient health questionnaire indicated mild levels of depressive symptoms. The Veteran reported that overall his life was "about the same" since the last examination in 2006. The examiner stated that his overall current psychosocial functioning appeared to be in the normal range, and there did not appear to be any significant decline since the last examination. The examiner noted that the Veteran's symptoms had worsened slightly since the last evaluation, in that he was experiencing irritability and acting out on anger verbally with family members, there were also now depressive symptoms, and his social interaction had decreased slightly. However, his family relationships and workplace performance continued to be in the moderate range. The examiner assigned a GAF score of 54. The Veteran was referred to the VA facility for treatment in May 2009 due to increased anger and depression over the last two months. VA treatment records dated in May 2009 reflect depression, nightmares, avoidance of trauma situations, and hypervigilance with tree lines. The Veteran was noted to have isolative behaviors, impaired judgment, and impaired recent memory. He reported being irritable at home with his spouse, his daughter and her two children who lived with them, and that the children were scared of him. He denied verbal or physical abuse. A depression screen showed mild depression with symptoms not at all or for several days, and that it was somewhat difficult for him to do his work and get along with others. The provider assigned a GAF score of 55, and prescribed an SSRI. A July 2009 VA treatment record reflects complaints of difficulties at work. The Veteran reported tension in the workplace, indicating that the apparent lack of respect for authority and social norms made him quite upset. The provider addressed ways to de-stress and not allow bullies to get away with it. The Veteran reported that his medications were effective and his wife had noticed a difference. In August 2009, the Veteran was noted to have anger and depression, but was doing well with current therapy and medication. He had good relationships with his wife, daughter and grandson who lived with them, and he was thinking of retiring from work. His family had noted positive changes in his anger management and insomnia, and he reported feeling well with stable mood. Later in August 2009, the Veteran reported depressed mood, irritability, and difficulty with concentration and job performance, and his medications were adjusted. In September 2009, he reported having more energy and ability to stay on task throughout the day with his medications. He felt much better, with more energy and better focus. In an October 2009 VA examination report, the examiner summarized the prior treatment records dated since 2005 and the examinations in 2006 and 2008. The Veteran continued to complain of anxiety, nervousness, irritability, moodiness, nightmares, frequent midnight awakening, and hypervigilance. He had mild distress and some physiological reactivity with thoughts of Vietnam, he avoided reminders and discussion of Vietnam, and he had increased anxiety and moodiness due to exposure to news about the current war. The Veteran was noted to be generally socially isolated and avoidant. The examiner stated that some of these symptoms had improved with medication. The Veteran was active with yard work, pool maintenance, and his dog, as well as with his children and grandchildren. He also spent time helping and advocating for veterans with the VSO. The examiner summarized that there was no change in the Veteran's psychosocial history since the last examination, although he had begun to take daily medication. He worked on a rural mail route with little interaction with others, which he preferred. He remained married to his wife of 39 years in a close and supportive relationship, and his daughter and her two children still lived with them. The Veteran's mother had recently moved to a nursing home due to Alzheimer's. During the examination, the Veteran was mildly anxious and his mood was "a little down." Judgment was noted to be good. The examiner assigned a GAF score of 60. He summarized that the Veteran described a mild increase in anxiety and irritability in the last six months, prompting him to seek out medication management. There was mild improvement in symptoms due to medications, and the symptoms continued to cause mild distress and little impairment in function. As noted above, the Veteran retired from his employment as a mail carrier in December 2009, at age 63. A January 2010 note from a VA therapist records that the Veteran started by sharing his abrupt decision to stop working, stating that he could not take the stress anymore, he was getting preoccupied with flashbacks and could not focus on driving, and that he stopped working because he was getting afraid. The Veteran reported inability to maintain focus and irritable mood despite medication. In March 2010, he was noted to be upset by the denial of his TDIU claim. In his view, it was a medical retirement because he could no longer continue to perform his duties due to increased PTSD symptoms. A May 2010 VA treatment record notes that the current level of psychiatric symptoms was moderate, and the Veteran had upcoming parade duties. In September 2010, he reported having lessened symptoms on medication, with reduced anxiety and irritability. He stated that his family agreed with this, especially his grandson with whom he had challenges. Treatment records reflect ongoing problems with his grandson, who had lived with him since early childhood, in 2010 due to the grandson's behavior and involvement in drug activities. In October 2010, a VA therapist stated that the Veteran was unemployable as likely as not due to a combination of medical and mental health diagnoses. In July 2011, the Veteran complained of difficulties with flashbacks, emotional flooding, dreams, and restless sleep from recent helicopter fly bys. He was also struggling with his grandson's maturation and time to leave the house. In August 2011, the Veteran complained of sleeping difficulties, frequent nightmares, daily startle response, and being very responsive to news of war. He also reported difficulties with concentration and focus. He stated that he avoided going places other than home or to the VA, he felt closed in and anxious, and he was guarded in restaurants and had difficulty in places with a lot of people. The Veteran was afforded another VA examination in August 2011. The examiner assigned a GAF score of 60, and summarized that there had been little change in circumstances, symptoms, and function since the last examination. The Veteran had occupational and social impairment due to mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner noted that the Veteran retired 18 months earlier after a successful postal service career, or from 1982 to December 2009. He remained married to his wife of 40 years. The Veteran had depressed mood, anxiety, chronic sleep impairment, and mild memory loss. He also had mild reactivity to reminders of his military trauma, dreams, anger, and social or crowd anxiety. The primary change since the last examination was retirement. There was also some increase in anger outbursts, which the Veteran attributed to stress at home with his grandson, as well as some increased marital friction as a result. However, the examiner stated that the Veteran continued to function adequately, with mild impairment noted. Per a November 2011 VA treatment record, the Veteran was doing well given the stressors of an early winter storm and its aftermath, including a lack of power and living with his son. His mental health symptoms were noted to be variable, and he still had recurrent nightmares, but they had not increased. He declined a dose adjustment on his medications. In February and April 2012, he was noted to be stable. He reported depression, stress, anxiety, and poor sleep because his grandson was involved with drugs again. In a September 2012 VA treatment session, the Veteran reported a good social support system, although he was irritable at times, and he stated that it helped to have his grandchildren at the house often. He was noted to be ambivalent about leaving the postal service, and was still adjusting to retirement. The Veteran stated that in some ways he was coerced into leaving because his concentration was very poor, which led to difficulties keeping up with the workload, and he also had concerns about driving in neighborhoods with children. The Veteran stated that he was also irritable, which led to negative feelings about his immediate supervisor. He began to feel overwhelmed, used all of his sick leave and annual leave, and began to dread work. The Veteran's therapist had told him at the time that since he had worked for 40 years he might want to retire. The provider summarized the January and October 2010 VA therapist notes as indicated above. The Veteran's current stressors included resolution of the situation with his 19-year-old grandson, who was back in school and off drugs, which also resulted in an improved relationship with his daughter and a feeling of relief. The Veteran's mood was mildly anxious, and his affect was mildly restricted but overall appropriate and reactive. The Veteran was again afforded a VA mental health examination in November 2012. He remained retired and had been very active in the VSO until resigning due to a conflict with the founder and director the prior week. He stated that he was relieved because it had become a chore. He was still active in taking his granddaughter to activities, babysitting with his wife once per week, taking care of the pool in the summer, caring for the dogs, and reading. He and his wife also hosted 20 family members at home for Thanksgiving. Nevertheless, his primary complaint was a lack of ambition, in that he did not feel like doing anything and had to push himself. He continued to take regular medications. The examiner noted the recent stressor of the trouble involving the 19-year-old grandson, who was now back living with the Veteran and was back in school and doing better. Current symptoms were chronic sleep impairment, nightmares, anxiety, irritability, and disturbances of motivation and mood. The Veteran became distressed on exposure to reminders of trauma, and had some mild avoidance of reminders. He described his mood as "blah," and he worried about cancer, diabetes, and his future morbidity. The examiner summarized that the Veteran had occupational and social impairment due to mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. He stated that there had been little significant change in condition since last exam in August 2011. The examiner opined that, although the medical records included some discussion of mental health symptoms contributing to the Veteran's decision to retire in December 2009, his adjustment disorder was not currently or at the time of retirement severe enough to prevent employment. He explained that the Veteran remained active and capable in retirement, with only mild impairment and a primary impediment of lack of motivation due to fatigue and dysthymia. Considering all available lay and medical evidence, the Board finds that the Veteran's symptoms have been relatively stable throughout the period on appeal. The VA examiners repeatedly noted that the Veteran continued to have similar symptoms and overall functional impairment as during the prior examinations. As discussed above, his symptoms include chronic sleep impairment with nightmares, flashbacks, depressed mood, and anxiety or nervousness (including in crowds). He was also suspicious or hypervigilant, with occasional exaggerated startle response. He had problems with anger and irritability to varying degrees, which resulted in some relationship difficulties at home and at work. There are also episodes of mild memory loss or difficulty concentrating. The Veteran has required daily medication to manage his symptoms since 2009. Although the Veteran's affect has varied depending on his mood, there has been no evidence of flat affect, and he has generally denied emotional numbing. The Board notes that the Veteran's reports in October 2008 of his heart pounding at times when thinking about distressing memories of service may be analogous to panic attack; however, there is no indication that these occurred more than once a week. Further, the Veteran's depression and anxiety or panic have not been so continuous as to affect his ability to function independently, appropriately, and effectively. Rather, he has been very active with family and other activities throughout the appeal. The Board acknowledges that there have been some times of increased stress or anxiety, as well as periods of increased anger and irritability, that resulted in disagreement with coworkers prior to his retirement and with his family members. Nevertheless, the Veteran has consistently maintained some social contacts, including at work, with a social couple, and through helping other veterans and participating in parades with the VSO. He has also maintained very close relationships with his wife, children, and grandchildren, including babysitting on a regular basis and reestablishing relations with his teenage grandson with school and drug problems. As such, although he has some interpersonal difficulties due to mental health symptoms, the evidence does not show the Veteran to have difficulty to establish and maintain effective relationships beyond that already reflected by the 30 percent evaluation presently in effect. The record contains no indications of abnormal speech or thought content, to include impaired abstract thinking, difficulty understanding complex commands, delusions or hallucinations. Although the Veteran was noted to have impaired judgment on one occasion in May 2009, it was otherwise found to be normal. Further, although he has had some mild memory loss and concentration difficulties, there is no indication of short or long-term memory loss, or of him forgetting the names of close relatives, his own occupation, or own name. Although he could not remember the names of service members, he could remember the details of service in detail. Further, although the Veteran has some anger outbursts and irritability, he consistently denied any verbal or physical abuse, or any history of violence or assault. He has also consistently denied suicidal or homicidal ideation, and there is no indication that he is a danger to himself or others. Additionally, the Veteran's suspicious and hypervigilant behaviors do not rise to the level of obsessional rituals or interfere with his routine activities. There is also no indication of disorientation, neglect of personal appearance or hygiene, or grossly inappropriate behavior. The Veteran has been assigned GAF scores ranging from 54 to 60. See May 2009 VA treatment record; October 2008, October 2009, August 2011, and November 2012 examination reports. The Board notes that a GAF score of 51 to 60 indicates the presence of moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). Further, VA examiners and providers have characterized the Veteran's symptoms and overall impairment as mild or moderate throughout the appeal. For example, the October 2008 examiner found that testing showed mild to moderate levels of posttraumatic symptoms, and mild levels of depressive symptoms. He also stated that the Veteran's overall functioning appeared to be in the normal range. Although the examiner noted that the Veteran's symptoms had worsened slightly, his family relationships and workplace performance continued to be in the moderate range. The October 2009 examiner noted that Veteran had mild increase in anxiety and irritability over the last several six months, and that there was mild improvement in symptoms due to medications. He summarized that the symptoms continued to cause mild distress and little impairment in function. After the Veteran's retirement in December 2009, the August 2011 and November 2012 VA examiners both opined that the Veteran's symptoms were mild or transient in nature. The August 2011 examiner noted that there were some increased anger issues and marital friction, but that the Veteran continued to function adequately. The November 2012 examiner stated that, although the 2010 medical records included some discussion of mental health symptoms contributing to the Veteran's decision to retire in December 2009, his adjustment disorder was not currently or that time severe enough to prevent employment. Rather, the Veteran remained active and capable in retirement, with only mild impairment. Although a VA therapist opined that the Veteran was likely unemployable in October 2010, this was stated to be due to both medical and psychiatric conditions. Neither the GAF score nor a medical professional's summary of the level of impairment is conclusive. Rather, all evidence of record that bears on social and occupational impairment must be considered together to arrive at a fair determination. See 38 C.F.R. § 4.126. Here, the Board finds that the VA examiners' summaries of the Veteran's level of function are consistent with the other evidence of record. Further, the Veteran's overall symptomatology has been relatively consistent throughout the appeal, as summarized above. Although the Veteran believes that his mental health symptoms severely affected his occupational performance and work relationships, and resulted in the need for him to retire in December 2009, this is not consistent with the evidence as a whole. Rather, the Veteran's symptoms resulted in mild to moderate occupational and social impairment with no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Further, the Veteran has had generally satisfactory functioning, routine behavior, self-care, and normal conversation. The Board acknowledges that the Veteran has had intermittently increased frequency and severity of certain symptoms, such as irritability, depression, and anxiety. He has also had manifested some symptoms that are contemplated by a higher rating, to include occasional difficulties with work and social relationships. Nevertheless, the Board finds that the Veteran's psychiatric symptomatology most nearly approximates the criteria for a 30 percent rating, and not any of the higher levels of disability. See 38 C.F.R. §§ 4.7, 4.130, DC 9413-9440. All potentially applicable diagnostic codes have been considered, and there is no basis upon which to assign an evaluation in excess of the currently assigned rating for the Veteran's PTSD. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Further, staged ratings are not appropriate, as the manifestations such disability have been relatively stable, and any increase is not sufficient to warrant a higher rating, for the reasons stated above. See Fenderson, 12 Vet. App. at 126-127. The Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). An extra-schedular rating is warranted if a case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that it would be impracticable to apply the schedular standards. Analysis under this provision involves a three-step inquiry, and extra-schedular referral is necessary only if analysis under the first two steps reveals that the rating schedule is inadequate to evaluate the claimant's disability picture and that such picture exhibits such related factors as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Here, the manifestations of the Veteran's psychiatric disability are fully contemplated by the schedular rating criteria. Briefly, the Veteran's mental health symptomatology resulted in occupational and social impairment due to symptoms such as those discussed above. Therefore, the rating criteria reasonably describe the disability level and symptomatology, and the rating schedule is adequate to evaluate the Veteran's disability picture. It is unnecessary to discuss the second prong, i.e., whether there are related factors such as marked interference with employment or frequent periods of hospitalization. See id. Moreover, there have been no hospitalizations for psychiatric disability during the course of the appeal. Although the Veteran retired in December 2009, and he reported some work difficulties due to his mental health prior to that time, there is no indication of marked interference. Rather, this interference is contemplated by the assigned rating, as the schedular percentages are intended to account for considerable interference with employment. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. As such, referral for consideration of an extra-schedular rating is not necessary. See Thun, 22 Vet. App. at 115-16. The Veteran's claim for a TDIU is being remanded as discussed below and, therefore, it will not be discussed further at this time. Finally, the Board has considered the benefit of the doubt rule. However, the preponderance of the evidence is against a rating in excess of the currently assigned rating for the Veteran's psychiatric disability. As such, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 C.F.R. § 4.3. ORDER A rating in excess of 30 percent for adjustment disorder with chronic anxiety is denied. REMAND As noted in the prior remand, the duty to assist with respect to a TDIU claim requires that VA obtain a medical opinion as to the effect the Veteran's service-connected disabilities on his ability to work. Friscia v. Brown, 7 Vet. App. 294, 297 (1994). The Board previously directed the RO to obtain an opinion as to whether the Veteran's service-connected disabilities preclude gainful employment. Although the RO provided the Veteran with a VA mental health examination to determine the severity of his psychiatric disability, there is no examination or opinion that addresses the effects of all of the Veteran's service-connected disabilities. The RO also did not address the issue of a TDIU in the December 2012 supplemental statement of the case, as required for due process. As noted in the prior remand, effective as of February 23, 2011, the Veteran was service-connected for the following disabilities: residuals of prostate cancer rated as 40 percent disabling, a psychiatric disability rated as 30 percent disabling, type II diabetes mellitus rated as 20 percent disabling, tinnitus rated as 10 percent disabling, and erectile dysfunction, assigned a noncompensable rating. His overall combined rating was 70 percent effective as of February 23, 2011. Prior to that date his combined rating was 60 percent, and he did not meet the percentage requirement for TDIU. See 38 C.F.R. §§ 4.16(a), 4.25. A TDIU may be awarded regardless of the percentage requirements under 38 C.F.R. § 4.16(b), but the Board cannot consider such entitlement in the first instance. Instead, the claim must be referred to VA's Director of Compensation and Pension for initial consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). The Veteran reports that he has been unemployed since December 2009. Although he voluntarily retired, he has asserted that his service-connected disabilities, and primarily his psychiatric disability, severely impacted his ability to function at his job. The Veteran's representative points to a statement in an October 2010 VA treatment record that the Veteran is unemployable, as likely as not, due to a combination of medical and psychiatric diagnoses. However, it is unclear what medical diagnoses were considered, and no explanation was provided. As the prior remand directives were not completed, the record does not include an opinion on the impact of the Veteran's service-connected disabilities on his employability. Therefore, the case must be remanded for development and completion of these items as set forth below. Stegall, 11 Vet. App. 268. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination to evaluate his TDIU claim. The claims folder should be made available to the examiner, and review of the file should be noted in the examination report. The examiner state whether it is at least as likely as not (50 percent probability or greater) that the Veteran is unable to secure or maintain substantially gainful employment consistent with his education and occupational experience as a result of his service-connected disabilities, either alone or in combination, and without regard for any nonservice-connected disorders. The Veteran's service-connected disabilities are: residuals of prostate cancer rated as 40 percent disabling, a psychiatric disability rated as 30 percent disabling, type II diabetes mellitus rated as 20 percent disabling (since February 23, 2011), tinnitus rated as 10 percent disabling, and erectile dysfunction evaluated as noncompensable. The examiner should note that the Veteran's primary work experience has been as a letter carrier for the postal service, and that he has completed some college. The examination report must include reasons for all opinions and conclusions reached. All pertinent lay and medical evidence should be considered. 2. If there remains any period during the appeal when the evidence shows that the Veteran was unemployable due to service-connected disability or disabilities, and he did not meet the percentage requirements for TDIU, refer the case to the Director of Compensation and Pension for adjudication in accordance with 38 C.F.R. § 4.16(b). 3. If any benefit sought on appeal is not granted in full, the agency of original jurisdiction should issue a supplemental statement of the case, and then return the case to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. All claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs