Citation Nr: 1310338 Decision Date: 03/27/13 Archive Date: 04/09/13 DOCKET NO. 07-01 520 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for paroxysmal atrial fibrillation, to include as secondary to service-connected anxiety disorder. 2. Entitlement to an initial evaluation in excess of 50 percent for an anxiety disorder. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from October 1969 to July 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In September 2011, the Board denied the claim for an initial evaluation in excess of 50 percent for an anxiety disorder, and remanded the claim for service connection for paroxysmal atrial fibrillation for additional development. The appellant appealed the issue of entitlement to an initial evaluation in excess of 50 percent for an anxiety disorder to the U.S. Court of Appeals for Veterans Claims (Court). In July 2012, while his case was pending at the Court, the VA's Office of General Counsel and appellant's representative filed a Joint Motion requesting that the Court vacate the Board's September 2011 decision. That same month, the Court issued an Order vacating the September 2011 Board decision. In May 2011, the Veteran testified during a video conference Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. FINDINGS OF FACT 1. The Veteran does not have paroxysmal atrial fibrillation that was caused by his service, or that was caused or aggravated by a service-connected disability. 2. For the period from January 20, 2004, when service connection for an anxiety disorder became effective, the evidence does not show that the Veteran's anxiety disorder results in occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The Veteran's paroxysmal atrial fibrillation was not caused by his service, nor was it caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for an initial rating in excess of 50 percent for an anxiety disorder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.321, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9413 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The Veteran asserts that service connection is warranted for paroxysmal atrial fibrillation. He argues that he developed this disorder during service in Vietnam, after he got sick from "some sort of bacterial infection." He essentially states that although he was displaying symptoms of this disorder during hospitalization, the service physician incorrectly told him that he did not have a problem. See e.g., Veteran's notice of disagreement, received in November 2005; Veteran's appeal (VA Form 9), received in May 2008. He has also claimed that this condition was aggravated by his service-connected anxiety disorder. See Veteran's statement, received in March 2010. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2012). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415 (1998); Cuevas v. Principi, 3 Vet. App. 542 (1992). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran's service treatment reports show that he was hospitalized in Japan in June 1971. The report notes that he had a passive aggressive personality. The diagnosis was psycho-neurotic conversion reaction, gastro-intestinal type, manifested by dysphagia, weight loss, moderate agitation with almost total denial of any emotional difficulties. The report does not mention complaints of, or the presence of, any heart symptoms, to include irregular heartbeat, or paroxysmal atrial fibrillation. The Veteran's separation examination report, dated in July 1971, shows that his heart was clinically evaluated as normal, and that in a signed statement, the Veteran stated, "I am in good health." As for the post-service medical evidence, it consists of VA and non-VA reports, dated between 1978 and 2011. This evidence includes a private treatment report, dated in May 1978, which notes "Arrhythmia by history," and which indicates that a Holter monitor was to be connected. Private treatment reports, dated in 1983, show treatment for heart palpitations, with use of medication to control symptoms (Lopressor), and hospitalization for his symptoms in 1985, and 2002. The diagnoses were paroxysmal atrial fibrillation. Overall, since 1985, the Veteran received a number of treatments for his symptoms, with multiple diagnoses of paroxysmal atrial fibrillation. A VA heart examination report, dated in June 2005, shows that the examiner stated that the Veteran's claims file had been reviewed. The impression was paroxysmal atrial fibrillation. The examiner concluded that it was not caused by, or a result of, anxiety. A VA heart examination report, dated in February 2010, shows that the examiner stated that the Veteran's claims file had not been reviewed. Based on physical examination, echocardiogram, and EKG (electrocardiogram), the examiner concluded that there was no diagnosis of ischemic coronary artery disease, and no diagnosis of atrial fibrillation at present. A VA heart examination report, dated in October 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The report notes the following: there was no history of myocardial infarction, congestive heart failure, heart valve condition, infectious heart condition, cardiac hypertrophy, or cardiac dilatation. There was no history of surgical or non-surgical procedures for treatment of a heart condition. There was no ischemic heart disease. An October 2011 echocardiogram showed normal wall motion and wall thickness. The Veteran's physical examination was normal, and his echocardiogram showed normal heart function with no atrial fibrillation. There was no evidence of anatomic changes in the heart secondary to atrial fibrillation. The diagnosis was atrial fibrillation, with no episodes in the last 12 months. The examiner concluded that the Veteran's atrial fibrillation was not caused by his service-connected anxiety disorder, stating that medical evidence did not support this association. He further stated that the Veteran's condition is less likely as not associated with his active duty service, explaining that studies show that the likelihood of young people having atrial fibrillation increases with structural heart disease, which the Veteran does not have, and that his active duty record is silent as to cardiac conditions. The examiner noted that models that attempt to predict the risk of development of atrial fibrillation have been developed, that hypertensive heart disease and coronary heart disease are the most common underlying disorders in patients with atrial fibrillation in developed countries, and that there was no evidence of cardiac damage in the Veteran. The examiner further concluded that the Veteran's condition had not been aggravated by his anxiety disorder, explaining that his current echocardiogram and ECG (electrocardiogram) showed him in sinus rhythm, and that there is no evidence of structural damage or cardiac anomaly. He further stated that studies show that 40 percent of AF (atrial fibrillation) patients will have atrial fibrillation-like symptoms in the absence of the disorder. The Board finds that the claim must be denied. The Veteran was not treated for atrial fibrillation (or any other heart disorder) during service, nor was atrial fibrillation (or any other heart disorder) noted upon separation from service. Therefore, atrial fibrillation (or any other heart disorder) was not shown during service. See 38 C.F.R. § 3.303(a). The earliest post-service medical evidence of atrial fibrillation (or any other heart disorder) is dated in 1978. This is about seven years after separation from active duty service. In this regard, the Veteran is not shown to have been diagnosed with a cardiovascular-renal disease, or valvular heart disease, which are the only heart disorders listed at 38 C.F.R. § 3.309(a) (2012), and the U.S. Court of Appeals for the Federal Circuit has recently held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a). Walker v. Shinseki, No. 10-2634, 2013 WL 628429 (Vet. App. May 25, 2011). In addition, the Board finds that the October 2011 VA opinion is highly probative evidence against the claim. In this opinion, it was essentially concluded that the Veteran's atrial fibrillation was not incurred in or caused by his service, and not caused or aggravated by his service-connected anxiety disorder. See 38 C.F.R. §§ 3.303, 3.310. The examiner indicated that the Veteran's claims files had been reviewed, and the opinion is accompanied by a sufficiently detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In summary, the evidence is insufficient to show that the Veteran has atrial fibrillation (or any other heart disorder) that was manifest in service, or that was caused or aggravated by a service-connected disability, and the Board finds that the preponderance of the evidence is against the claim. Hence, the claim must be denied. In reaching this decision, the Board has considered a statement from Dr. C.S.B., dated in January 2012, in which he states: [The Veteran] is a patient of mine. He has a history of paroxysmal atrial fibrillation. He also has a history of anxiety and panic attacks. It is possible that when he has a panic or anxiety attack it can increase incidents of atrial fibrillation. Dr. C.S.B. does not indicate if his opinion is based on a review of the Veteran's claims file, or any other detailed and reliable history. It is speculative in its terms, summary in nature, and it is unaccompanied by citation to clinical studies or other authority. Prejean; Nieves-Rodriguez. Therefore, the Board finds that Dr. C.S.B.'s rationale is insufficient, and that his opinion is insufficiently probative to warrant a grant of the claim. As a final matter, with regard to the possibility of service connection based on exposure to Agent Orange, the Veteran is shown to have served in Vietnam, and is therefore presumed to have been exposed to Agent Orange. However, the applicable law does not include paroxysmal atrial fibrillation as a condition for which presumptive service connection may be granted on this basis. See 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). The evidence shows that the Veteran does not have ischemic heart disease. See 75 Fed. Reg. 14391 (March 25, 2010); 38 C.F.R. § 3.309(e). Furthermore, there is no competent evidence of record which associates a currently demonstrated heart disorder, to include paroxysmal atrial fibrillation, with exposure to Agent Orange. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Accordingly, service connection is not warranted on this basis. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The issue on appeal is based on the contention that the Veteran has paroxysmal atrial fibrillation due to service, or as secondary to service-connected disability. To the extent that the Veteran has asserted that he began having irregular heartbeat symptoms during service, his statements are competent evidence to show that he experienced these symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). However, the Veteran does not have the requisite skills, knowledge, or training, to be competent to state whether his symptoms were sufficient for a diagnosis of paroxysmal atrial fibrillation, or whether the claimed disability is related to his service, or to his service-connected anxiety disorder. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, paroxysmal atrial fibrillation falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the Veteran's service treatment records do not show complaints of, treatment of, or a diagnosis, involving an irregular heartbeat, or any other heart symptoms. His post-service medical records do not note atrial fibrillation prior to 1978, which is about seven years after service. A VA health care provider has issued an opinion in which it was determined that the Veteran's paroxysmal atrial fibrillation is not related to his service, or to a service-connected disability. Given the foregoing, the Board finds that the service treatment reports, and the post-service medical evidence, outweigh the Veteran's contentions to the effect that he has atrial fibrillation that is related to service, or to a service-connected disability. The Board has considered the applicability of "benefit of the doubt" doctrine, however, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant the resolution of this matter on that basis. 38 U.S.C.A. § 5107(b). Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. II. Increased Rating The Veteran asserts that he is entitled to an initial evaluation in excess of 50 percent for his service-connected anxiety disorder. In statements, dated in November 2010 and May 2011, the Veteran said that he thought that his anxiety disorder met the criteria for a 70 percent rating for the following reasons: when he went to work he had panic attacks every day; he cannot deal with any kind of stress; his first wife left him due to his anxiety and his current wife was having a hard time staying; he was put on medication because of his moods; he cannot function independently without help and medications; and he has problems sleeping and gets up to check the doors and windows. During his videoconference Board hearing in May 2011, the Veteran testified that he was having a lot of problems and led a "miserable life." He said that his symptoms had worsened and he was recently prescribed medication because he was having a lot of panic attacks. He said that he had been in counseling since 2004. He found it stressful to leave his home to go to work and felt like a prisoner in his own house, but was essentially ok at work during the day. The Veteran testified that besides being hypervigilant about the house he had bought high fluorescent lights to keep his house lit up at night. He also said that he thought that he met a lot of the symptoms described in the criteria for a 70 percent rating because of his isolation and family difficulties. He stated that his first wife divorced him because of all his problems, but his current wife had been very sympathetic and had stuck by him. The Board notes that given the basis of the July 2010 Joint Motion, discussed infra, the Board's September 2011 analysis is largely repeated herein. Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207 -08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14 (2012). As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As a layperson the Veteran is only competent to report observable symptoms, but not the clinical findings which are applied to VA's Rating Schedule. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2012). The Veteran's anxiety disorder rating has been adjudicated pursuant to the rating criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). Under that code and the General Rating Formula for Mental Disorders, ratings may be assigned ranging between 0 and 100 percent. A 50 percent disability rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); and inability to establish and maintain effective relationships. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a) (2012). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors, with no more than slight impairment in social, occupational or school functioning. Historically, the Veteran was granted service connection for an anxiety disorder in an August 2005 rating decision, and awarded a 30 percent disability rating, effective January 20, 2004, the date the Veteran's service connection claim for an anxiety disorder was received at the RO. He appealed this initial rating in a November 2005 Notice of Disagreement, or within 12 months of being granted service connection for an anxiety disorder. Subsequently, in December 2006, the RO increased his disability rating from 30 percent to 50 percent, effective January 20, 2004. Because this increase did not constitute a full grant of the benefits sought, the increased initial evaluation issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The relevant medical evidence is summarized as follows: A VA mental examination report, dated in July 2005, shows that the Veteran complained of chronic problems with anxiety since two incidents in service. He said that his symptoms had worsened as he grew older, including sleeping problems, excessive worrying, hypervigilance, irritability, panic attacks, and an inability to relax. He reported that he had worked for Union Carbide (now Cryogenics) as a welder and pipe fitter, for the past 28 years. He was married to his second wife for 27 years. He had two children from his first marriage and two from his current marriage and enjoyed a good relationship with all. The Veteran denied any history of drug or alcohol abuse or any legal problems. On mental status examination, the Veteran was alert and oriented times four, was appropriately groomed, and demonstrated good personal hygiene. He was noted as obviously very anxious and nervous throughout the examination. He became tearful, more agitated, and developed a tic in his left eye when he began discussing his traumatic experiences in Vietnam. His mood was described as anxious; affect was congruent; thought content and processes were within normal limits; and no inappropriate behavior was noted. There was no evidence of delusions or hallucinations or gross memory loss or impairment and he denied suicidal or homicidal ideation. His speech was coherent and of a normal rate and volume. It was noted that the Veteran was not currently receiving any psychiatric treatment and had not received any treatment since he was discharged from military service. Diagnosis was generalized anxiety disorder, with an assigned GAF score of 51. A VA mental examination report, dated in July 2008, shows that the Veteran complained of anxiety on a daily basis, constant restlessness and being fatigued as a result of sleeping difficulties, and occasional feelings of depression and helplessness. The examiner noted that his depressive feelings appeared more associated with his anxiety than a separate diagnosis in and of itself. The Veteran said that sometimes he was afraid to go to work at 5 a.m. because it was still dark out and he was afraid of being attacked. He denied working a swing shift, but said that he had been verbally reprimanded at times for being late for work. It was noted that the Veteran was afraid to go out when dark because he was fearful of being attacked. For example, he ran to the mailbox in the morning to retrieve the paper. He claimed that this arose from a sexual assault in Vietnam. It also was noted that the Veteran was obsessively worried about his youngest son's safety, although he was less obsessive when his son was away at school. The Veteran stated that he went to the gym three days a week, and that he went to a nearby college to watch his son play baseball. On mental status examination, the Veteran was oriented to person, place, time and situation. Psychomotor activity and speech functions were within normal limits and eye contact was intermittent. Thought content was mildly concrete and thought processes were goal-directed. He denied hallucinations and delusions. He described his mood as anxious and on edge. He appeared somewhat anxious with a congruent affect. Personal hygiene and grooming were adequate. Insight was marginal concerning his symptoms and judgment was functional. Memory functions were grossly intact with respect to recent and remote recall. He denied suicidal or homicidal ideation. He maintained his own activities of daily living independently, and there were no significant impairments in thought processes or communications. The examiner noted that the Symptom Trauma Inventory test suggested that the Veteran over-reported or over-endorsed symptomatology. The diagnosis was generalized anxiety disorder, with a GAF score of 55 assigned. The examiner opined that this anxiety disorder adversely affected his psychosocial and occupational functioning and quality of life to a moderate degree. She noted that he preferred isolative tasks and admitted to emotional sensitivity. She stated that the Veteran said he had no friends but was quite close to his wife. Insight was marginal concerning his symptomatology, and judgment appeared functional. The examiner also opined that the Veteran's prognosis was guarded because of the chronicity of his symptoms, his advanced age, and virtually no treatment. The Veteran underwent a private psychological evaluation in September 2009 by L.S.L., Ph.D. Current symptoms included: "living in fear;" severe distrust of African Americans; easy startle; fear of strangers; inability to empty the garbage at night; intrusive thoughts about traumatic events in Vietnam; racing heart, palpitations, and panic attacks on a weekly basis. The diagnosis was PTSD, with an assigned GAF score of 50. A VA PTSD examination report, dated in October 2010, shows that the Veteran complained of panic attacks every morning when he got up to go to work. He also complained of sleep difficulties, including a recurring dream twice a week. The Veteran also claimed that he was "living a lot in fear right now" because he was scared of African Americans, since a black service member had sexually molested him at knifepoint in Vietnam. He described these symptoms as of mild to moderate severity since service, and denied taking any medications for his anxiety. It was noted that the Veteran worked full-time as a welder and pipe fitter for the past 32 years and that work was going very well. On mental status examination, the Veteran was noted as fully oriented, well-groomed and cooperative. His mood was described as mildly anxious with full and reactive affect. He denied suicidal intent or planning, homicidal ideation, hallucinations, and delusions. Attention, memory, and judgment appeared to be within normal limits. Diagnosis was generalized anxiety disorder with a GAF score of 75 assigned. However, this GAF score was based only on objectively assessed PTSD symptomatology. A PTSD diagnosis was not given because the Veteran's documented mental health history and the results of objective testing did not conform to the DSM-IV guidelines for the diagnosis of PTSD. A VA mental examination report, dated in January 2011, shows that it was noted that the Veteran was not taking medications for any mental disorder, but that he was receiving individual counseling at the Vet Center. The Veteran complained that he had "a hard time enjoying life right now." He told the examiner that all he essentially did was go to work and come home. He also said that when he got anxious leaving home or leaving work his palms got sweaty, his hand shook, and his heart "started racing real hard and fast." He also said that sometimes he called his youngest son three or four times a day and got real worried if he could not find him. He also admitted to an outburst at work the year before that he felt unable to control, when he threw chairs and dumped over garbage cans. On mental examination, the Veteran was oriented to person, place, and time. His thought process and content were noted as unremarkable. His general appearance and affect were appropriate and his speech was spontaneous, clear and coherent. He denied delusions, hallucinations, and suicidal and homicidal thoughts. A sleep impairment with nightmare was noted and his hypervigilant checking of windows and doors at night was described as obsessive or ritualistic behavior. While his remote memory was normal, his recent and immediate memory were described as mildly impaired. It also was noted that the Veteran stated that he had lost an estimated two to three weeks from work during the past year because of his anxiety. The diagnosis was generalized anxiety disorder and a GAF score of 52 was assigned. The VA examiner concluded that the Veteran's symptomatology was fairly consistent with his July 2008 VA examination. She also concluded that the Veteran's symptoms were most consistent with the criteria for reduced reliability and productivity, i.e., the criteria for his current 50 percent disability rating. An April 2011 VA medical record shows a recent psychiatric consultation after a referral from the Vet Center and his VA primary care provider for evaluation and treatment of anxiety. The Veteran complained of recurrent nightmares of sexual assault about twice a week, anxious difficulties leaving home, panic attacks, and poor sleep. He also complained of depressed feelings, passive morbid thoughts, poor concentration, and a residual fear of young male African Americans. On mental status examination, the Veteran was noted as oriented to person, place, time and situation. An anxious and subdued affect and mood were noted, but the Veteran denied suicidal and homicidal ideations and hallucinations as well as obsessions and compulsions. The diagnoses were PTSD, and panic disorder with agoraphobia. A GAF score of 48 was assigned. The VA psychiatrist also noted two prescriptions for anxiety. In a May 2011 letter from T.B., a licensed certified social worker at the Mobile, Alabama Vet Center, it was disclosed that the Veteran had been a client since April 2004 and was currently being seen in individual counseling to address his complaint of PTSD as a result of military sexual trauma, more consistently within the past three years. She stated that the Veteran had all the symptoms of PTSD along with a history of untreated severe depression and severe anxiety. She stated that he planned to remain in treatment at the Vet Center for weekly individual counseling and at the VA mental health clinic for psychiatric treatment and medication monitoring. The Board finds that the Veteran does not warrant an initial evaluation in excess of 50 percent for the Veteran's anxiety disorder. The Veteran has reported symptoms that include, nightmares, reliving past experiences, and fear of African American males. However, there is insufficient evidence to show such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships, nor are there other psychiatric symptoms shown to have resulted in such impairment. In this regard, the Veteran has been described as appropriately groomed in all the VA examinations of record. There is no evidence that his speech was intermittently illogical, obscure, or irrelevant. While there is evidence noting obsessive checking of windows and doors at night, there is no evidence of obsessional rituals which actually interfere with his routine activities. The Veteran has always denied suicidal and homicidal ideation or thoughts. There was no evidence of spatial disorientation and, in fact, the Veteran was oriented to person, place, and time during his VA examinations. The most recent medical evidence shows that the Veteran has worked full-time as a welder and pipe fitter at the same company for more than 30 years, and that he has good relationships with his wife and adult children. The Veteran's GAF scores (51, 52, and 55) are primarily indicative of moderate symptoms or some difficulty in functioning, which are well within the criteria for the assigned 50 percent rating. His lower GAF scores (48 and 50) are evidence of serious mental health symptoms, however, the accompanying findings do not warrant an evaluation in excess of 50 percent. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003) (although a GAF score may be indicative of a certain level of occupational impairment, it is only one factor in determining an appellant's degree of disability). His score of 75 (in October 2010) is evidence of transient and expectable reactions to psychosocial stressors, and no more than slight impairment in social, occupational or school functioning. Accordingly, an initial evaluation in excess of 50 percent is not warranted. In reaching this decision, the Board has considered the July 2012 Joint Motion, which indicates that the Veteran has some symptoms which interfered with his work. The Joint Motion states, "Remand is necessary because the Board only focused on Appellant's specific symptomatology and failed to address the overall occupational and social impairment caused by Appellant's anxiety disorder and whether this overall impairment was equivalent to the impairment contemplated by the increased rating criteria." It was further agreed that on remand, "[T]he Board should more fully consider how Appellant's symptoms affected his overall occupational and social impairment and provide an adequate statement or reasons or bases in that regard." The Board has fully considered how the Veteran's symptoms affected his overall occupational and social impairment. However, a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this regard, the Veteran's submitted employment records indicate that during a four-month period in 2007 (September to December), he reported for work at 7 a.m. instead of 5 a.m. on 18 occasions, that in each case he completed either an 8 or 10-hour shift (except for one 6-hour shift), and that in each case the status was "approved." There are also three entries which indicate that he worked from 6 p.m. to 2 a.m., and in each case the status was "approved." No reasons for the variations in his schedule are noted. During his July 2008 VA examination, the Veteran denied significant absenteeisms or suspensions for problems on the job, and the examiner noted that he had worked at the same job for 31 years. The examiner specifically discussed the Veteran's employment records, stating, "While his schedule in his C-file does indicate that there are times periodically that he goes in at 7:00 a.m., there is no evidence to suggest his schedule is changed because of being too fearful to go in at 5:00 A.M. There is no report from his supervisors as to the reasons for these changes in schedule." A March 2010 statement from C.W.J., a Vet Center social worker, notes that the Veteran had returned to work after some orthopedic surgery, and that, "but does not adapt well in the working environment which adds to his bouts of depression and anxiety." Service connection is not currently in effect for any disabilities other than an anxiety disorder, and this report therefore suggests that (nonservice-connected) orthopedic conditions may be contributing to the Veteran's work difficulties. In addition, during his October 2010 VA examination, the Veteran complained that when he gets anxious leaving home, or leaving work, his palms got sweaty, his hands shake, and his heart starts racing "real hard and fast." He also complained that he had an outburst at work the year before that he felt unable to control when he threw chairs and dumped over garbage cans. However, despite his complaints, the Veteran stated, "Work goes very well." The report notes that he has worked full-time as a welder and pipefitter for 32 years. The October 2010 VA examiner further stated, "The Veteran's reported impairment in social and occupational functioning is not adequately corroborated by any collateral information available to the examiner." Finally, during his January 2011 VA examination report, the Veteran claimed that he had lost two to three weeks of work in the past 12 months due to his symptoms (there is no objective evidence of this). However, the examiner concluded that his symptoms were "fairly consistent" with those shown during his July 2008 VA examination (which inter alia showed that he maintained his own activities of daily living independently, that there were no significant impairments in thought processes or communications, which concluded that there was no more than a moderate degree of impairment, and which resulted in a GAF score of 55). In summary, the Veteran's symptoms are not shown to be sufficiently severe to have resulted in occupational and social impairment, with deficiencies in most areas, and the Board has determined that the preponderance of the evidence shows that the Veteran's anxiety disorder more closely resembles the criteria for not more than a 50 percent evaluation. As such, the Board finds that the preponderance of the evidence is against the Veteran's entitlement to an initial disability rating in excess of 50 percent for an anxiety disorder. The Board has considered the Veteran's assertions that his anxiety disorder warrants a higher initial rating. The Board has considered the statements of the Veteran as to the extent of his anxiety disorder over the entire course of this appeal. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular disability rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). While he is competent to report that his symptoms are worse, the training and experience of medical personnel makes the medical findings found in treatment notes and examinations more probative as to the extent of the disability. See Cromley v. Brown, 7 Vet. App. 376, 379 (1995). Consideration has been given to assigning a staged rating for this claim; however, at no time during the time period in question has the Veteran's anxiety symptoms warranted the assignment of a rating higher than what has been herein affirmed. See Fenderson, 12 Vet. App. at 126. In conclusion, the Board finds that the criteria for an initial disability rating in excess of 50 percent for an anxiety disorder have not been met. Where, as here, the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's anxiety disorder does not warrant referral for extra-schedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. In this case, the Veteran has not expressly raised the matter of entitlement to an extra-schedular rating for his service-connected anxiety disorder. The Veteran's contentions have been limited to those discussed above, i.e., essentially that his disability is more severe than reflected by the currently assigned ratings. See Brannon v. West, 12 Vet. App. 32 (1998) (while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant). In this case, there has been no showing that the Veteran's disability picture for his anxiety disorder could not be contemplated adequately by the applicable schedular rating criteria discussed above. Those criteria provide for higher ratings in this case, but as has been explained thoroughly herein, the currently assigned ratings adequately describe the severity of the Veteran's symptoms. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's anxiety disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Referral for consideration of the assignment of a disability rating on an extra-schedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). III. VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) and as interpreted by the United States Court of Appeals for Veterans Claims (the Court), have been fulfilled by information provided to the Veteran in letters from the RO dated in May 2005, January 2008, and January, March, and December of 2010. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, and identified the Veteran's duties in obtaining information and evidence to substantiate his claims. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). Thereafter, the Veteran was granted service connection for an anxiety disorder and assigned an initial disability rating and effective date. As this claim was more than substantiated in that it was proven, the purpose that the notice is intended to serve has been fulfilled and no additional notice is required for this claim. Dingess, 19 Vet. App. at 490-91. Pursuant to Dingess, an additional notice as to disability ratings and effective dates was provided in the correspondence dated in March 2006, January 2008, and December 2010. In addition, since the higher initial rating claim for an anxiety disorder is a "downstream" issue from that of service connection, notice pursuant to the original Court decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), was never required for this issue. See VAOPGCPREC 8- 2003 (Dec. 22, 2003). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service treatment reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's VA and non-VA medical records. In this regard, in April 2010, the Keesler Air Force Base reported that it did not have any records for the Veteran. The Veteran has been afforded examinations, and etiological opinions have been obtained. In September 2011, the Board remanded the claim for service connection. The Board directed that the RO/AMC should schedule the Veteran for an appropriate VA examination to assess the nature and etiology of his claimed atrial fibrillation. In October 2011, this was done. The Board finds that the examination report obtained is more than adequate, as it is predicated on a review of the pertinent evidence, consideration of the Veteran's lay statements, and an examination of the Veteran. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion with respect to the service connection issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2012). Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In view of the above, the Board finds that the notice requirements pertinent to the issues on appeal have been met. In summary, the Board finds that the available medical evidence is sufficient for an adequate determination of the claim on appeal. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims does not cause any prejudice to the Veteran. ORDER The appeal is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs