Citation Nr: 1309793 Decision Date: 03/22/13 Archive Date: 04/01/13 DOCKET NO. 10-02 141 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a higher initial disability rating for the service-connected generalized anxiety disorder, rated as 30 percent disabling from October 12, 2007 to September 30, 2008, and rated as 50 percent disabling thereafter. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from June 1975 to April 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbus, South Carolina, which granted service connection for generalized anxiety disorder effective from October 12, 2007 and assigned an initial disability rating of 30 percent. In September 2008, only five months after the RO's April 2008 rating decision, VA received a submission from the Veteran requesting that it consider an increase in the assigned 30 percent disability rating. This submission is considered a timely Notice of Disagreement asserting entitlement to higher initial disability ratings for generalized anxiety disorder, particularly because the Veteran asserted that additional VA records would support his claim, and he requested VA to obtain those records on his behalf. After receipt of additional evidence, the RO issued a new rating decision in November 2008, which granted an increased disability rating of 50 percent for generalized anxiety disorder, effective from October 1, 2008. The Veteran's appeal for higher initial disability ratings has been styled as reflected on the title page of this decision to reflect the staged periods provided by the RO's rating decisions in this case. At the Veteran's request, a hearing before a Decision Review Officer (DRO) at the Charleston RO was scheduled to be held in August 2009. Notice of the date, time, and place of the hearing was mailed to the Veteran in July 2009, but the Veteran did not appear at the scheduled hearing. VA has not received any request from the Veteran or his representative to reschedule the DRO hearing. The Veteran did not request a Board hearing and the Veteran's claim for higher initial ratings for the service-connected generalized anxiety disorder was denied by a Board decision issued in December 2011. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (CAVC or Court). While his claim was pending at the Court, the appellant and the Secretary of VA (the parties) filed a Joint Motion for Remand with the Court, requesting that the Court vacate and remand the Board's December 2011 decision. In a December 2011 Order, the Court granted the Joint Motion and the case was returned to the Board for compliance with the directives set forth in the Joint Motion. FINDINGS OF FACT 1. Since the effective date of service connection, the Veteran's generalized anxiety disorder has been manifested by a disability picture that more nearly approximates that of occupational and social impairment with reduced reliability and productivity, due to symptoms of depressed mood, near-continuous anxiety and worry, occasional suicidal ideation without specific plan or intent; isolative behavior, intermittent and mild impairment of memory and concentration, increased anger; and, occasional panic attacks, and Global Assessment of Functioning (GAF) scores throughout the appeal period of approximately 50. 2. At no time since the effective date of service connection has the service-connected generalized anxiety disorder been manifested by a disability picture that more nearly approximates that of deficiencies in most areas such as work, school, family relations, judgment, thinking or mood due to such symptoms as obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; and inability to establish and maintain effective relationships; nor is total occupational and social impairment shown. CONCLUSION OF LAW The criteria for an initial disability rating of 50 percent, but no higher, for generalized anxiety disorder have been more nearly approximated since the effective date of service connection. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159 , 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012) and 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1) , proper 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; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A pre-rating letter mailed to the Veteran in October 2007 provided notice of the information and evidence needed to substantiate a claim for service connection for an anxiety disorder. This notification would also apply to the "downstream" issue of entitlement to a higher initial rating. The United States Court of Appeals for Veterans Claims (Court) has held that once service connection is granted, the claim is substantiated. In such instances, additional notice regarding VA's duty to notify and assist the Veteran is not required and any defect in the notice is not deemed prejudicial to the Veteran. Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007); Dingess, 19 Vet. App. at 491. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. His service treatment records, claims submissions, and identified VA treatment records have been obtained and associated with the record. VA psychiatric examinations were afforded to the Veteran in December 2007, October 2008, and September 2009 and VA has not received any additional evidence since that time which indicates that the Veteran's condition has changed such as to warrant the scheduling of a new VA examination to reassess the symptoms and severity of his anxiety disorder. Hence, these examinations along with the other evidence of record, provide a fully adequate basis for determining the extent of the Veteran's disability in light of the applicable diagnostic criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007). A November 2009 VA treatment record references that the Veteran began receiving social security disability benefits at that time. When the evidence indicates that the Veteran is in receipt of social security disability payments, VA's duty to assist requires that it seek the Social Security Administration's disability determination and the medical records underlying it only when these records are relevant to the claims. See Golz v. Shinseki, 590 F.3d 1317, 1320-1321 (Fed. Cir. 2010). In this instance, however, there is no indication that the Veteran was seeking social security disability benefits in connection with his anxiety disorder, which is at issue here; and moreover, the VA outpatient treatment records refer the Veteran's claim(s) for social security disability benefits in relation to his numerous physical disabilities. Neither the Veteran nor his representative has asserted that his social security file may contain any additional evidence that is relevant to his anxiety disorder. With regard to the Veteran's inability to work, he has always maintained that his physical limitations caused his unemployability and that his psychiatric disability came later. Under the circumstances, the Veteran's social security records are not potentially relevant to the issue on appeal and would merely impose unnecessary burdens on VA's adjudication system, with no benefit flowing to the Veteran, and moreover, cause additional delay in this appeal. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (citing Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991)) (remand is not required when it would impose unnecessary burdens on VA adjudication system with no benefit flowing to the veteran). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. II. Initial Disability Ratings Service connection for generalized anxiety disorder was granted pursuant to an April 2008 rating decision. The RO assigned an initial disability rating of 30 percent from October 12, 2007. The Veteran appealed that determination. Before the Veteran perfected his appeal to the Board, the RO issued another rating decision in November 2008, whereby the 30 percent rating was increased to 50 percent, effective from October 1, 2008. As this award is not a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155 ; 38 C.F.R. § 4.1 . In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate when the factual findings show distinct time periods during which the service-connected disability exhibits symptoms that would warrant the assignment of different disability ratings for each distinct period. 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 . When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The evaluation will be based on all the 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 examination. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Global assessment of functioning (GAF) scores, which reflect the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health, are also useful indicators of the severity of a mental disorder. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). GAF scores ranging between 51 to 60 are indicative 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 co-workers). GAF scores between 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores between 31 to 40 range indicate impairment in reality testing or communication (e.g., speech is 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 QUICK REFERENCE TO THE DIAGNOSTIC CRITERIA FROM DSM-IV, 46-7 (1994). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 31, 1995). Under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9400, a 30 percent disability rating is appropriate where the evidence shows that generalized anxiety disorder is productive of occupational and social impairment with an 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, or mild memory loss (i.e., forgetting names, directions, and recent events). A 50 percent disability rating is assigned for generalized anxiety disorder that is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is appropriate where generalized anxiety disorder is manifested by 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 that is 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); or the inability to establish and maintain effective relationships. A 100 percent disability evaluation is granted where generalized anxiety disorder is productive of 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 himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; or memory loss for the names of close relatives, own occupation, or own name. As discussed above, service connection for generalized anxiety disorder was granted effective from October 12, 2007 and an initial disability rating of 30 percent was assigned pursuant to DC 9400, for the period from October 12, 2007 through September 30, 2008. Although the Veteran has expressed disagreement with the assigned initial disability rating, he does not express any disagreement with the effective date of service connection. Upon review and consideration of the evidence in the claims file, the disability picture presented by the Veteran's generalized anxiety disorder for the identified staged period more nearly approximates the criteria for a higher, 50 percent rating. VA treatment records, which encompass treatment received by the Veteran since November 2005, document that the Veteran received psychiatric treatment beginning in August 2007 and that such treatment consisted largely of monthly counseling with a VA social worker. Overall, the VA treatment records from August 2007 through September 2008 reflect consistently reported symptoms of sadness, anergia (lethargy), a sense of being overwhelmed, worry, regret, fluctuating temper, and difficulties with concentration. An October 2007 mental health note reveals that the Veteran was quite effusive during the interview and difficult to redirect, though polite. In that same report, the Veteran stated that his marriage was good. The records reflect further that the Veteran consistently denied having symptoms such as nightmares, hypervigilance, or impulsivity. A mental status examination performed by the Veteran's VA social worker in August 2007 revealed that the Veteran maintained good hygiene and was dressed casually. No evidence of psychomotor agitation was observed. The Veteran's speech was normal in rhythm, tone, and volume. Overall, the Veteran's mood appeared to be euthymic with congruent affect. Nonetheless, the Veteran's thought process was logical, goal-directed, and linear. The Veteran denied having any hallucinations or delusions. His cognition was intact and he appeared to be alert and oriented in all spheres. Judgment and insight were described as being good. Although the Veteran reported sleep disturbances, he attributed such disturbances to physical pain in his legs, which he stated was keeping him awake. The Veteran's memory and concentration were described as "good with some difficulties..." A Global Assessment of Functioning (GAF) scale score of 65 was assigned. At a September 2007 interview with his VA social worker, the Veteran reported similar symptoms to those reported at his August 2007 treatment, noting in particular, chronic anxiety and depressive symptoms. Medications helped to control his irritability somewhat. A mental status examination was largely unchanged from the Veteran's August 2007 examination. The Veteran's mood was depressed and agitated. Additionally, judgment, insight, memory, and concentration were apparently diminished from his August 2007 examination, as the social worker described those as being only "fair." Notably, the Veteran was assessed a GAF score of 51, which is a sharp departure from the GAF score of 65 that had been assigned the previous month. At a December 2007 VA examination, the Veteran reported symptoms of depression, anxiety, and occasional sleep problems. He said that all of his mental health problems became worse about a year and a half earlier. Regarding his sleep problems, the Veteran reported at that time that he had been diagnosed with sleep apnea and was using a CPAP; hence, he appeared to attribute his sleep disturbances to his sleep apnea rather than his psychiatric symptoms. The Veteran described the frequency of his anxiety and depression as "all the time" and indicated that "It sort of messed up my life with all the thoughts of suicide." Occupationally, he stated that he was not working. Socially, he reported that he remained married to his spouse of 22 years. He did not report any marital difficulties or difficulties in relating to his spouse. He did state, however, that he had no social activities." A mental status examination performed at that time did not indicate any impairment of thought process or communication. The Veteran denied having any hallucinations or delusions. His eye contact and interaction during the interview was lively and he demonstrated good hygiene. The Veteran was well-oriented to situation, person, place, and time and he denied having any memory loss or obsessive or ritualistic behavior. His speech was normal in rate, prosody, and volume and his cognition was good. The Veteran denied panic attacks. Suicidal ideation was noted by the examiner. Based upon the demonstrated symptoms, the examiner found the Veteran's generalized anxiety disorder to be chronic and moderate, and also diagnosed adjustment disorder with depressed mood. The Veteran assessed a GAF score of 62. The examiner noted that he was not provided with the claims file for review in conjunction with the examination. Thus, the examiner was not able to review the Veteran's monthly therapy notes. In August 2008, the Veteran reported to his VA social worker that he was not doing well, either physically or mentally. A mental status examination performed at that time revealed that the Veteran continued to maintain good hygiene. His mood remained anxious with a worried affect. He continued to be alert and oriented in all spheres, and he continued to deny having hallucinations or delusions. His memory and abstraction remained intact and his judgment and insight were good. In contrast to his prior examinations, however, the Veteran was notably preoccupied with his physical symptoms and demonstrated some mild psychomotor agitation. The Veteran's speech was slightly pressurized and thought process was noted as being circumstantial and catastrophizing. A current GAF score of 52 was assigned, and it was noted that this was the highest Global Assessment of Functioning (GAF) score within the prior year. In September 2008, the Veteran returned to his VA social worker complaining of increased anxiety and depression. He appeared to endorse stress in the form of financial problems and stated that he and his wife were meeting an attorney the next day with an eye on filing for bankruptcy. Regarding his symptoms, the Veteran reported that he felt depressed five out of seven days a week. He stated that the severity of his depression was such that he struggled to brush his teeth and that he cared for his dogs only because he must and that he struggled through doing so. Another mental status examination revealed that the Veteran continued to show good hygiene and demonstrated behavior that was within normal limits. His speech continued to be normal in rate, tone, and volume and his mood remained depressed and anxious. Again, the Veteran denied having any hallucinations or delusions. His thought process was intact, logical, and goal-directed, and his memory and orientation remained intact. Judgment and insight continued to be rated as being "fair to good." A GAF score of 52 was assigned. A September 2008 depression screen was positive because the Veteran indicated that he had little interest or pleasure in doing things more than half the days; and, that he felt down, depressed or hopeless more than half the days. The screening also found the Veteran positive for a suicide risk. In view of the foregoing evidence for the period from October 12, 2007 through September 30, 2008, the Veteran's anxiety disorder has been consistently manifested by symptoms that are consistent with the criteria for a 50 percent disability rating under DC 9400. In this regard, the Veteran's symptoms consistently included depressed mood, anxiety and worry, and intermittent and mild impairment of memory and concentration. These symptoms resulted in reduced reliability and productivity. As noted in the medical evidence summarized above, the Veteran had near-constant depression, worry and anxiety. He had one bout of suicidal ideation, and he struggled with anger and irritability. The Veteran was able to find some relief with medications, but overall, the evidence shows that he was not generally functioning satisfactorily. He sought regular therapy and all of his testing and assessments indicated that the severity of the Veteran's mental health condition was of a moderate degree. During this period the Veteran's symptoms may have waxed and waned from day to day, as noted in the outpatient mental health notes and assessments, as well as by the Global Assessment of Functioning (GAF) scores provided throughout this period. At some points during the period between October 12, 2007 through September 30, 2008, the Global Assessment of Functioning (GAF) score was as low as 51, and at other times it was as high as 65. Overall, however, when the entire disability picture is viewed throughout this period, the level and frequency of the Veteran's main symptoms of anxiety and depression appear to have remained fairly consistent throughout the appeal period. Although the Veteran was not employed during this period, his most prominent symptoms of anxiety and depression, along with the anger, irritability, and sadness clearly establishes occupational and social impairment with reduced reliability and productivity. The Veteran's level of disability during this time period does not more nearly approximate that of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The Veteran has described his relationship with his wife as "good" but has also noted some anger toward her. Nonetheless, the Veteran remains married to his wife, and has not indicated that there is social deficit in this area. In other words, despite some difficulties with intimacy, the Veteran and his wife have a social relationship and he has not indicated that the relationship is in danger of falling apart. Although the Veteran may have difficulty with relationships, a complete deficiency is not shown. Moreover, the Veteran is not deficient with regard to judgment or thinking. As is shown in the medical records, the Veteran has always had a logical thought process, has always been able to communicate effectively with his health care providers, and has always been oriented in all spheres. The Veteran's hygiene has consistently remained adequate. Additionally, although the Veteran reports symptoms of anger, this anger has never led to physical outbursts or impaired impulse control. Similarly, the Veteran has been shown to be a suicide risk, with one prior in-service incidence of suicidal ideation; however, at every examination and every assessment during the period covered by this claim, the Veteran has reported no suicidal ideation. In other words, the evidence does not consistently show that the Veteran exhibits suicidal ideation such that the severity of his overall disability would more nearly approximate the criteria for the assignment of a 70 percent rating. The Veteran's speech, thought content, and thought process were consistently noted as being within normal limits, logical, and goal-directed, and hence, were not indicative of circumstantial, circumlocutory, or stereotyped speech. Although the Veteran endorsed frequent depression, he did not report any panic attacks, much less panic attacks which occurred more than once a week. Further, there is no indication in the records that the Veteran experienced any difficulty in understanding complex commands. As acknowledged above, the Veteran's immediate memory, judgment, and insight appeared to fluctuate between being "fair" and "good." Nonetheless, there is no evidence that the Veteran experienced impairment of long and short-term memory, nor is there evidence of impaired judgment. Finally, the Veteran's Global Assessment of Functioning (GAF) scores are indicative of moderate disability, with some scores reflective of only mild symptoms. However, the Global Assessment of Functioning (GAF) scores of 51 and 52 are in the lower range of moderate; and the Global Assessment of Functioning (GAF) scores of 62 and 65 are in the lower to middle range of mild. Thus, when averaged, the result is a moderate overall disability picture. Accordingly, the Veteran's symptomatology is consistent with the assignment of an initial 50 percent disability rating, and no more, under DC 9400 for the service-connected generalized anxiety disorder for the period from October 12, 2007 through September 30, 2008. Similarly, the evidence from October 1, 2008 continues to show the same symptoms of depression and anxiety. Effective from October 1, 2008, the Veteran's generalized anxiety disorder has been rated as being 50 percent disabling, pursuant to the rating criteria under DC 9400. Upon review and consideration of the evidence in the claims file, the overall severity of the Veteran's generalized anxiety disorder has remained fairly stable. The criteria for entitlement to a disability rating in excess of 50 percent for the generalized anxiety disorder are not met at any time since the initial grant of service connection, to include the period on and after October 1, 2008. At an October 2008 VA examination, the Veteran reported "almost crippling depression" which he rated as an 8.5 in severity on a scale of ten. He described that he felt suicidal but stated that he had not acted on such thoughts. He also reported a complete loss of motivation and that he did not want to go anywhere or do anything. The Veteran endorsed crying episodes and stated that he felt dread as well as anxiety, particularly while driving among traffic. Socially, the Veteran stated that he disliked being among crowds, and that in such situations, he felt as though everything was closing in on him, which caused him to panic. He stated that his only social support is his spouse, although he described his relationship with her as being more of a "roommate situation." The Veteran stated that he had one friend with whom he corresponded over the internet. He stated that he spent most of his time on the computer. He also described problems with anger and irritability; although he denied ever striking his spouse, he stated that he has come close to doing so. Of note, the Veteran stated that he has a genetic blood disorder, called Leiden Factor V blood clotting disorder, which makes him hypersensitive to blood clotting. According to the Veteran, problems from this disorder surfaced in 1999 after he developed a blood clot in his right knee. He reported that he was treated with medication and was able to continue working as an exterminator. In 2002, however, he was involved in a motor vehicle accident in which he developed another blood clot in his right knee. The Veteran stated that he has not worked since that time and has experienced six blood clots in his lungs and also two pulmonary embolisms which have resulted in constant pain. The Veteran also reported that he has sleep apnea, hypertension, and is also a borderline diabetic. Functionally, the Veteran stated that he limits his driving because of the physical problems in his leg. He also reported that he sleeps a lot during the daytime as he does not sleep well at night, presumably due to sleep apnea. Finally, the Veteran reported that he experienced trouble maintaining his focus due to his pain medications. A mental status examination revealed that the Veteran was demonstrating various physical limitations manifested by use of a cane for ambulation and difficulty sitting for long periods of time. His speech was normal in rate and rhythm and his eye contact was fair. The Veteran's thought content and process were logical and goal-directed. Nonetheless, the Veteran's mood was depressed and his attention and concentration did appear impaired, as described by the Veteran. Based upon the findings on examination, the examiner diagnosed recurrent and moderate major depression. The examiner determined further that the Veteran was unemployable due to his chronic health condition. Finally, he opined that as a result of his psychiatric disorder, the Veteran had very limited socialization and that his temper and irritability was affecting his relationship with his spouse. A GAF score of 45 was assigned. Although a lower Global Assessment of Functioning (GAF) score of 45 was assigned, the examiner's assessment of the Veteran's disability picture and the Veteran's report of symptoms does not differ significantly from prior reports. While the Veteran continued to have logical and goal directed thought content and process, he nevertheless continued to experience near-constant moderate depression. In addition, the Veteran once again reported suicidal thoughts, but specifically stated that he would not act on them. The Veteran's reports of a complete loss of motivation are consistent with his previous reports of isolative behavior. The Veteran's reports of crying episodes, feelings of dread, and anxiety are also consistent with previous reports of feeling sadness, depression and anxiety. The Veteran continued to report spousal support, although he also continued to report that there were problems with intimacy ("more like a roommate situation"). Finally, the Veteran's reports of anger and irritability were also consistent with previous reports. The Veteran did report having feelings of panic on occasion, which was not specifically reported previously. Subsequent VA treatment records through 2009 show that the Veteran continued to receive monthly counseling with his VA social worker. In general, mental status examinations performed throughout 2009 revealed that the Veteran continued to demonstrate good hygiene; was alert and oriented in all spheres; behavior which was within normal limits; speech which was grossly normal in rate; anxious mood with worried affect; impairment of recent memory; psychomotor agitation which was perhaps reflective of physical pain and discomfort; and thought processes which were grossly intact, albeit somewhat ruminative or tangential at times. Judgment and insight continued to range between fair and good. GAF scores throughout 2009 were consistently in the range of 50. In addition to the symptoms which were consistently shown by the Veteran during mental status examinations in 2009, the Veteran appeared to become increasingly agitated and irritated over the course of that year. At an August 2009 evaluation with his social worker, the Veteran demonstrated speech which was loud and with an increased rate. His thought process at that time was noted as being significantly ruminative, and for the first time, his recent and remote memory were both noted as being impaired. At a September 2009 evaluation, the Veteran began reporting the occurrence of nightmares and paranoid delusions. His thought process continued to be ruminative. Significantly though, a September 2009 mental health outpatient follow up note indicates that the Veteran was doing ok with his medications and his mood. He reported a decrease in his anger and impulsivity. He described his mood as less irritable. The report notes no suicidal or homicidal ideation. The report also notes that his relationship with his wife was stable. On a mental health status examination, the Veteran's mood was euthymic, with less anger and occasional anxiety. Behavior was normal with a relaxed body posture. The Veteran was conversational, with good eye contact. Global Assessment of Functioning (GAF) was 55. In November 2009, he was noted as being extremely agitated and irritated due to administrative processes with the Social Security Administration and VA. Mental status examination at that time revealed the Veteran as being anxious and tearful. His thought processes were tangential and his recent and remote memory continued to be impaired. Concurrent with his VA counseling, the Veteran was also afforded a new VA psychiatric examination in September 2009. At that time, he continued to report sleep difficulties, anger problems, concentration problems, and lack of interest in pleasurable activities. Socially, he stated that he no longer had friends and was isolative. He stated that he experienced anxiety attacks and felt safer at home. The Veteran stated that he was still not working, but again, acknowledged that his inability to work was due to physical disabilities. He reported long-term memory loss. The Veteran's speech was noted as being relevant, logical, strong, opinionated, and testy. Interestingly, the Veteran stated that his impulse control was kept in check by medications. Once again, the Veteran stated that he was only getting three to four hours of sleep per night; nonetheless, the Veteran appeared to attribute his sleep disturbances to physical discomfort, and stated that he had to constantly move in order to find comfort. The examiner also reviewed a March 2009 letter from the Veteran's social worker. The entirety of the letter is re-typed verbatim in the VA examination report. In the letter, the Veteran's social worker opined that the Veteran was experiencing "overwhelming" anxiety and depression on a daily basis. According to the social worker, the Veteran attempted to commit suicide during his active duty service, and the Veteran remained ashamed of that to this day and experienced nightmares about the incident. According to the social worker, the Veteran avoided memories of that experience, and was now also experiencing sleep difficulties, anger problems, concentration problems, and was no longer enjoying pleasurable activities. According to the social worker, the Veteran no longer attempted to seek friendships and also experienced hyperarousal symptoms such as frequent panic attacks. In summary, the Veteran's social worker opined that the Veteran was severely limited by his anxiety. Based upon the Veteran's history, the examiner's review of the claims file, and the findings on examination, the examiner diagnosed generalized anxiety disorder and assessed a GAF score of 52. The above evidence suggests that the Veteran's overall disability picture has remained fairly stable throughout the period from October 1, 2008. Although there are periods where the Veteran reports increased anxiety and irritability, the medical evidence does not suggest that these isolated periods are representative of an overall disability picture. The Veteran has always endorsed the same symptoms of near-continuous depression and anxiety, worry, sadness, irritability, isolation; and more recently, some panic attacks. The Veteran has described periods of suicidal ideation in the past, the there is none presently; and moreover, the Veteran has specifically indicated that he would not act on any such ideation. The record reflects some of the Veteran's symptoms, such as sadness, isolation, and worry, which are not explicitly identified in the schedular criteria. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, 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 DSM-IV (American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). In this case, as detailed below, the Board concludes that the level of occupational and social impairment due to the symptomatology of the Veteran's service-connected generalized anxiety disorder is adequately reflected by a 50 percent rating, for the entire period covered by this appeal. As with the previous staged period prior to October 1, 2008, the Global Assessment of Functioning (GAF) scores have been indicative of moderate impairment. The Veteran has always been able to communicate effectively with his doctors, has the support of his wife, and although he argued that he had a lack of motivation, the evidence shows that he continued to fight for social security disability benefits even after they were initially denied. Thus, while the Veteran certainly exhibits symptoms of occupation land social impairment with reduced reliability, he is not deficient in most areas. The Veteran's generalized anxiety disorder has been manifested by symptoms which are consistent with the criteria for a 50 percent disability rating, and no more, under DC 9400. In this regard, the Veteran's symptoms consistently included near-continuous depression, anxiety, sadness, anger, irritability, intermittent panic attacks; impairment of short and long-term memory; occasionally impaired judgment; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges that the Veteran's disorder has also been manifested by suicidal ideation, albeit without specific plan or intent; however, as noted above, the Veteran is not deficient in most areas. The Veteran had one period during 2009 where his symptoms appeared to be worsening; however, subsequent mental health records, as noted above, showed a waning of these symptoms, particularly due to medication adjustments. The Veteran has never engaged in obsessional rituals which interfere with routine activities, which the Veteran has repeatedly and expressly denied. Although the Veteran's thought process has been noted as being ruminative and tangential at times, there is no evidence that the Veteran's speech is intermittently illogical, obscure, or irrelevant, as demonstrated in repeated mental status examinations since October 2008. Similarly, despite reported increase in irritability, the Veteran has not reported any impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran has also been consistently noted as demonstrating good hygiene, and therefore, there is no evidence of neglect of personal appearance and hygiene. Finally, the evidence shows that the Veteran continued to be married to, and living with, his spouse of 22 years. Although there is evidence showing that the Veteran's symptoms have impacted the quality of his relationship with his spouse, there is no evidence supporting that the Veteran has experienced a complete inability to establish and maintain effective relationships. More importantly, the Veteran's anxiety, depression, irritability, panic, sadness, and mild memory impairment with rare suicidal ideation to do collectively show occupational and social impairment with deficiencies in most areas. Certainly impairment is demonstrated, but it is not so severe as to result in a disability picture that more nearly approximates the criteria for the assignment of a rating in excess of 50 percent. Even assuming, arguendo, that the Veteran's symptoms slightly worsened after October 2008, the evidence of record does not demonstrate a worsening to the point that the criteria for the assignment of a rating in excess of 50 percent are met for the service-connected generalized anxiety disorder; and, moreover, other evidence dated in 2009 shows periods of improvement. The Veteran's GAF scores, for the period since October 1, 2008 range from 45 to 55, with the majority in the 50 to 52 range. Despite the Global Assessment of Functioning (GAF) scores under 51, no mental health professional has described the Veteran's overall disability picture as more than moderate in degree. In essence, the assignment the 50 percent disability rating for the entire period covered by this appeal represents an overall disability picture when taking into consideration all of the evidence of record, and not focusing on one particular medical record. In this case, the rating is based on the consistency of symptoms since service, with some worsening of symptoms and some lessening of other symptoms throughout. There is no identifiable time period since the effective date of service connection where the Veteran's overall disability picture appears to have worsened to the point that the criteria are more nearly approximated for the assignment of a 70 percent rating. The Board acknowledges that the Veteran continued to be unemployed after October 1, 2008. As noted above, however, there continues to be no evidence showing that the Veteran's inability to work is attributable to his psychiatric symptoms. Once again, the Veteran appears to acknowledge as much, as at his October 2008 and September 2009 VA examinations, he stated that his unemployment was due to physical limitations secondary to his genetic blood clot disorder. Additionally, the evidence since October 2008 does not show that the Veteran has been hospitalized or has required any in-patient therapy for treatment of his anxiety disorder. In addition, the Veteran has not been hospitalized or undergone any in-patient therapy for treatment of his anxiety disorder, and the Veteran's symptoms associated with the generalized anxiety disorder are fully contemplated by the rating schedule. The Veteran's depression, anxiety and other symptoms, when considered together, more nearly approximate a disability picture that is compatible with occupational and social impairment with reduced reliability and productively, but occupational and social impairment with deficiencies in most area such as work, school, family relations, judgment, thinking or mood is not shown. The Veteran's signs and symptoms, as discussed in detail above, fit within the rating criteria as was discussed above. There is no showing that the rating criteria are inadequate. The signs and symptoms shown in this case which were described above are contemplated by the schedular criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (use of the phrase "such symptoms as," followed by a list of examples, 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 Veteran's social and work situation). Moreover, the assignment of a 50 percent rating signifies that he has commensurate industrial impairment. Accordingly, the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) have not been met. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Under the circumstances, there is no basis to remand this matter for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) for consideration of extraschedular ratings for the service-connected generalized anxiety disorder. The Veteran's symptoms are fully contemplated by the schedular criteria. See Thun v. Peake, 22 Vet. App. 111 (2008). Accordingly, the Veteran's symptomatology is consistent with a 50 percent disability rating, and no more, under DC 9400 since the effective date of service connection. As such, the Veteran is entitled to an initial disability rating of 50 percent for the service-connected generalized anxiety disorder from October 12, 2007; a rating in excess of 50 percent for generalized anxiety disorder is not warranted for any time period covered by this appeal. ORDER Entitlement to an initial disability rating of 50 percent, but no higher, for the generalized anxiety disorder from October 12, 2007 is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 50 percent for the service-connected generalized anxiety disorder is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs