Citation Nr: 1312583 Decision Date: 04/16/13 Archive Date: 05/02/13 DOCKET NO. 03-31 469 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a brain disorder, including organic brain syndrome and leukodystrophy. 2. Entitlement to an initial rating in excess of 20 percent for a seizure disorder. 3. Entitlement to an initial rating in excess of 10 percent for hypoactive sexual desire disorder. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from October 1983 to September 1992 from January 1995 to August 1996, and from October 1996 to October 1997, with additional inactive duty service in the Army National Guard of California. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in Portland, Oregon (RO). This case was remanded by the Board in June 2005, September 2009, and September 2011 for additional development. The Veteran has had two hearings which are relevant to the issues on appeal. The first hearing was held in March 2005 before one of the undersigned Veterans Law Judges (VLJ). That hearing covered the issues of entitlement to service connection for a brain disorder, a psychiatric disability, and a seizure disorder. The claims were then remanded by the VLJ who conducted that hearing in June 2005 and September 2009. Subsequently, a March 2011 rating decision granted service connection for a psychiatric disability and a seizure disorder. The Veteran then perfected an appeal as to the ratings assigned for those disabilities in April 2012. In June 2012, a second hearing was held before the other two undersigned VLJs. The second hearing covered all three issues currently on appeal. As the Veteran's psychiatric disorder and seizure disorder claims are currently before the Board on the basis of increased ratings, rather than service connection, the March 2005 hearing does not constitute a hearing on those issues. As a result, the Veteran has had a hearing before all three undersigned VLJs on the issue of entitlement to service connection for a brain disorder, but has only had a hearing before two of the undersigned VLJs on the issues of enlistment to increased initial ratings for hypoactive sexual desire disorder and a seizure disorder. As three different VLJs held hearings in this appeal, the following decision will be reviewed and signed by a panel of three VLJs, which includes the VLJs who presided over the March 2005 and June 2012 hearings. 38 C.F.R. §20.707 (2012). A veteran is entitled to have an opportunity for a hearing before all Board members who will ultimately decide the appeal. Arneson v. Shinseki, 24 Vet. App. 379 (2011). A letter was sent to the Veteran in November 2012 notifying her that she had the option of having a third hearing with a VLJ who would be assigned to the panel to decide her claims for increased initial ratings for hypoactive sexual desire disorder and a seizure disorder. The letter informed the Veteran that if she did not respond within 30 days, the Board would assume that she did not want any additional hearing. The Veteran did not respond to that letter within 30 days. Therefore, the Board finds that there is no hearing request pending at this time. 38 C.F.R. § 20.700(a) (2012). Therefore, the Board will proceed with adjudication of the claims. The issue of entitlement to service connection for a brain disorder, including organic brain syndrome and leukodystrophy, is remanded to the RO via the Appeals Management Center, in Washington, D.C. FINDINGS OF FACT 1. The medical evidence of record shows that the Veteran's psychiatric disability was initially manifested by depression, nightmares, sleep impairment, decreased libido, fear of the dark, anxiety, panic attacks, anger, irritability, hyperactivity, racing thoughts, excessive worrying, easy startlement, and an abnormal mood. 2. Upon VA examination on December 13, 2010, a clear decrease in the severity of the Veteran's psychiatric disorder symptomatology was shown, and that decrease in symptomatology has been shown to have continued to the present day. 3. The preponderance of the evidence of record demonstrates that the Veteran's seizure disorder is manifested by less than five minor seizures weekly. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 30 percent, but not higher, for psychiatric disability have been met from March 22, 2001, until December 12, 2010. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating in excess of 10 percent for psychiatric disability, for the period on and after December 13, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 3. The criteria for an initial rating in excess of 20 percent for a seizure disorder have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8912 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claims with adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in January 2002, October 2002, March 2006, April 2007, and June 2008. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and her representative suggest actual knowledge of the elements necessary to substantiate the claims. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the February 2012 statement of the case and March 2012 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist her in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). In resolving the factual issue, the Board may only consider the specific factors enumerated in the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). The appeal of the Veteran's hypoactive sexual desire disorder and seizure disorder claims is based on the assignment of initial ratings following an initial award of service connection. Therefore, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial ratings were assigned and should be the evidence used to decide whether an original rating on appeal was erroneous. If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson v. West, 12 Vet. App. 119 (1999). Hypoactive Sexual Desire Disorder Service connection for hypoactive sexual desire disorder was granted by a March 2011 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective March 22, 2001. The Veteran's hypoactive sexual desire disorder claim was originally raised as a claim for service connection for posttraumatic stress disorder (PTSD). There are multiple psychiatric reports of record which include multiple diagnoses of various psychiatric disorders, including hypoactive sexual desire disorder and PTSD. The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In addition, in this case there is no evidence of record which would allow the Board to determine which psychiatric symptoms are related to her service-connected hypoactive sexual desire disorder and which are exclusively related to some nonservice-connected psychiatric disorder. When it is not possible to separate the effects of a service-connected disorder and a nonservice-connected disorder, the signs and symptoms should be attributed to the service-connected disorder. Mittleider v. West, 11 Vet. App. 181 (1998). Accordingly, the Board shall adjudicate the Veteran's hypoactive sexual desire disorder claim as encompassing all of her psychiatric symptoms, regardless of the specific diagnosis assigned to them in any particular record. In an August 2000 VA neuropsychology examination report, the Veteran reported that she was working at a telemarketing job through a temporary agency, and was beginning work as a receptionist the following week. She reported that she was very active during the week with her church, including bible study twice a week and choir practice once a week, and occasionally serving as a substitute teacher for bible school. On diagnostic testing, memory impairment was noted. The diagnosis was cognitive disorder, not otherwise specified. In a December 2000 VA general psychiatric consultation report, the Veteran reported that she had been unemployed since May 2000. She reported that she had been having anxiety attacks several times per week since a motor vehicle accident in 1998. On mental status examination, the Veteran was neatly dressed, very pleasant, and appeared to be her stated age. She was alert and oriented to time, place, and person. She had some problems with recent memory, concentration, and abstraction, but for the most part appeared to be maintaining her activities of daily living at an acceptable level, and she was able to manage her affairs. The Veteran showed poor judgment about a new personal relationship and reported having some depressive symptoms with lack of motivation and a low energy level. The examiner stated that the symptoms did not meet the criteria for a major depressive disorder, and the Veteran denied suicidal ideation and hopelessness. She reported experiencing chronic nightmares, and anxiety several times per week including palpitations and feeling overwhelmed. The Veteran denied experiencing psychotic symptoms, but appeared impulsive with fair insight and judgment. The Axis I diagnosis was PTSD, chronic; cognitive disorder not otherwise specified; and history of past major depressive disorder without currently meeting the full criteria. The examiner assigned a Global Assessment of Functioning (GAF) score of 55, which contemplates moderate symptoms, such as flat affect, circumstantial speech, or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as few friends and conflicts with peers or co-workers. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). In a December 2000 VA Vet Center report, the Veteran reported a history of military sexual trauma and being unable to maintain employment. On subsequent mental status examination, the Veteran's appearance was neat, her manner was friendly and cooperative, her speech was appropriate, and she was oriented to time, place, and person. The Veteran's memory was impaired, but her affect was appropriate, her motor activity was relaxed, and her judgment was fair. The Veteran reported that she had cerebral cortex deficits largely in her short term memory. There was no evidence of delusions, hallucinations, or disorganized thinking. Her appetite was average and she did not have any recent weight change, but she experienced sleep disturbance with nightmares and frequent waking. The Veteran reported having a non-existent sex drive and a fluctuating energy level. She denied experiencing suicidal thoughts, but reported homicidal thoughts without intent to harm. In a February 2001 VA outpatient psychiatry note, the Veteran reported that she was working part-time as a receptionist but was looking for different work due to sexual harassment. She denied experiencing nightmares and depression, but reported being frightened by the sexual harassment and very frustrated by her financial difficulties. The Veteran reported that she was very close to friends in her church and socialized with them on a regular basis. The assessment was adjustment disorder; PTSD; cognitive disorder, not otherwise specified, related to seizure disorder; and cluster B personality disorder. In a February 2001 VA outpatient medical report, the Veteran reported that she was experiencing poor sleep, loss of interest or loss of pleasure in life, panic attacks or anxiety attacks, excessive worrying, memory problems, disturbing nightmares or memories, phobia of the dark, learning disorders, anger control problems, temper, concentration problems, hyperactivity, and racing thoughts. She also reported that she had previously experienced a depressed or sad mood, panic attacks or anxiety attacks, excessive worrying, anger control problems, temper, and racing thoughts. She did not report having suicidal thoughts, self-harm behaviors, obsessions, compulsions, eating disorders, hearing voices or having visions, impulse control problems, being physically violent, or having thoughts of harming someone. The Veteran reported having numerous hobbies or interests, including attending various church functions three days a week. In a second February 2001 VA outpatient psychiatry note, the Veteran reported that she was in a new relationship but that it was potentially abusive. She reported that she had lots of support from her church and girlfriends, and had recently been promoted in the Army Reserves. The Veteran appeared very histrionic and reported that she was looking for a job as a receptionist. The assessment was adjustment disorder; PTSD; cognitive disorder, not otherwise specified, related to seizure disorder; and cluster B personality disorder. In a March 2001 VA mental health evaluation note, the Veteran reported that she began experiencing panic attacks in 1997. She reported that the panic attacks occurred every few days and lasted about 20 minutes, with symptoms of dry mouth, needing to urinate, feeling out of control, feeling intense fear, and difficulty swallowing. The Veteran reported experiencing nervousness at other times, but denied depression and anhedonia presently. She reported experiencing a decreased libido and some irritability and stated that her sleep was usually good with occasional middle insomnia. The Veteran reported that her appetite was good. She stated that since a sexual assault during active service, her self-esteem had decreased, she startled more easily, and she experienced anger. The Veteran also reported experiencing decreased short-term memory and concentration problems which she first noticed in 1993. She reported having employment difficulties due to her concentration and memory problems, and stated that she had recently been fired from a job after a few weeks because she would not go on a date with her boss. The Veteran denied any prior suicide attempts or perpetrating violence. She reported that she was divorced and lived alone, but stated that she had friends and was involved in a church. On mental status examination, the Veteran was casually dressed and well groomed. Her facial expressions were very exaggerated but she was pleasant. Her speech was of regular rate and rhythm, but her mood was anxious and she had a dramatic affect at times. The Veteran's thought processes were somewhat tangential at times, but she denied suicidal ideation, homicidal ideation, and disturbances of perception. The Veteran was oriented to all spheres. She reported having poor concentration and short-term memory, but appeared to have a good fund of knowledge, fair judgment, and questionable insight. The Axis I diagnoses were rule out panic disorder, rule out PTSD, adjustment disorder with anxiety and anxious mood, and cognitive disorder not otherwise specified. The examiner assigned a GAF score of 50, which contemplates serious symptoms, such as suicidal ideation, severe obsessional rituals, or frequent shoplifting, or serious impairment in social, occupational, or school functioning, such as no friends or an inability to keep a job. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). In a March 2001 VA Vet Center report, the Veteran reported that she had been fired from a job for allegedly making "too many errors," but she reported that she was fired for refusing to have sex with her employer. She reported that since that time she had been experiencing panic attacks approximately twice a week, particularly when she was out after dark. The assessment was severe childhood trauma, many unresolved issues, unable to sustain employment, and anxiety attacks. In a March 2001 VA outpatient mental health note, the Veteran reported continuing panic attacks which occurred about every other day and lasted for a few minutes. She reported that during a panic attack she felt cold all over, needed to urinate, felt anxious, and felt "weird." She was unsure if she hyperventilated and denied any chest pain, numbness, and tingling. On mental status examination, the Veteran had a wide affect and organized thought processes. She denied suicidal ideation, homicidal ideation, and disturbances of perceptions. She reported having panic attacks, but denied depressive symptoms. The examiner noted, however, that the Veteran looked tearful when talking about her personal life. The assessment was rule out PTSD, cluster B personality features. A second March 2001 VA Vet Center report stated that the Veteran was experiencing anxiety attacks with some agoraphobia, although she was able to leave her home. In an April 2001 VA outpatient mental health note, the Veteran reported a decrease in her panic attacks. The Veteran was noted to have lower self-esteem and hypervigilance to the dark, but she denied anger dyscontrol and depressive symptoms. She reported some recent insomnia but denied intrusive memories. On objective examination, her affect was bright but her thought processes were tangential. She denied suicidal ideation, homicidal ideation, and disturbances of perceptions. The assessment was history of panic attacks, adjustment disorder with anxious mood, and partial PTSD symptoms. In a May 2001 VA Vet Center report, the Veteran stated that she was employed in a support staff position, having been hired following a three week probationary period. She reported that she had not had any anxiety attacks since she started working. A November 2002 VA neurological disorders examination report stated that, on mental status examination, the Veteran's speech was fluent and articulate. She had full orientation and her attention and concentration appeared to be intact. There were some subtle deficits in her memory and fund of knowledge. The diagnosis was organic brain syndrome as evidenced by progressive cognitive impairment. In a July 2004 VA telephone note, the Veteran complained of fear at night, anxiety, and an inability to sleep. The Veteran reported that she had anxiety two years before but it went away after she got more deeply involved in religion. She reported that she was so fearful she did not want to go on with her life, but denied being suicidal or depressed. An addendum stated that the Veteran complained of poor sleep, anxiety, and feelings of panic. She reported that she would discontinue caffeine and denied suicidal and homicidal ideation. The Veteran had a positive sense of humor and was encouraged to call if the anxiety did not resolve. The Veteran thought that the symptoms were not related to PTSD issues. In an August 2007 VA neuropsychology consultation report, the Veteran denied having symptoms of psychological distress or symptoms consistent with psychosis. A June 2008 VA emergency department note stated that, on examination, the Veteran was alert and oriented to time, place, and person; obeyed commands; and was cooperative. An August 2009 VA emergency department note stated that, on examination, the Veteran was alert and oriented to time, place, and person; obeyed commands; and was cooperative. A December 2009 VA emergency department note stated that, on examination, the Veteran was alert and oriented to time, place, and person; obeyed commands; and was cooperative. A January 2010 VA nursing note shows that, on mental status examination, the Veteran was alert, oriented, cooperative, and anxious. A second January 2010 VA nursing note shows that the Veteran had an odd affect at times A January 2010 VA emergency department note shows that, on examination, the Veteran was alert and oriented to time, place, and person; obeyed commands; and was cooperative. A May 2010 VA emergency department note shows that, on examination, the Veteran was alert and oriented to time, place, and person; obeyed commands; and was cooperative. In a November 2010 VA emergency department note, the Veteran denied experiencing any current issues related to a history of military and childhood sexual assault. In a December 2010 VA mental disorders examination report, the Veteran stated that she had been employed by VA for the previous eight years and was not particularly concerned about her finances. She reported that she was engaged and that her fiancé was her caregiver. On mental status examination, the Veteran was well-groomed, pleasant, and rather upbeat, but appeared somewhat older than her stated age. Her speech was somewhat slow and she had difficulty articulating her words at times. She reported that she felt that she had a delay in recalling her thoughts and putting them into words, but that was minimally relevant on interview. Her thought processes were linear and no psychotic features were present. She did not have suicidal ideation, but came to tears on multiple occasions during the interview. She reported having a decreased interest in sex which she felt was related to her previous sexual assault. The Veteran was very positive and had a bright affect when discussing her relationship with her fiancé. The examiner stated that she did not meet the criteria for PTSD and she scored 30 out of 30 on a mini-mental status examination. Her judgment was intact and she showed good insight. The Veteran reported that she liked to cook, crochet, and play computer games. She reported that she had one very close girlfriend who was a support to her. The Axis I diagnosis was hypoactive sexual desire disorder, acquired type. The examiner assigned a GAF score of 71, which contemplates transient and expectable reactions to psychosocial stressors, such as difficulty concentrating after family argument, or no more than slight impairment in social, occupational, or school functioning, such as temporarily falling behind in school work. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). In a June 2012 hearing before the Board, the Veteran reported that she experienced nightmares, lack of sexual desire, fear of the dark, anxiety, depression, and sleep impairment. She reported that she had previously had panic attacks, but no longer noticed them. The Veteran reported significant short-term memory impairment. She reported that she did not feel like she needed to see a doctor for treatment because she "kind of got over it in a way." The Veteran reported that her symptoms were "no big deal as far as [she was] concerned." The Rating Schedule provides that a 10 percent rating is warranted for psychiatric disorders with occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 30 percent rating is warranted for psychiatric disorders with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, mild memory loss, such as forgetting names, directions, recent events. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent rating is warranted for psychiatric disorders with 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 such as, 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. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 70 percent rating is warranted for psychiatric disorders with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 100 percent rating is warranted for psychiatric disorders with total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Initially, the Board notes that the medical evidence of record includes numerous complaints and diagnoses of impairment of memory and concentration. However, the medical evidence of record overwhelmingly demonstrates that the symptoms are related to the Veteran's currently diagnosed brain disorder, not her service-connected psychiatric disorder. Therefore, those symptoms are not for consideration in conjunction with the psychiatric disorder claim on appeal, and the Board shall not discuss them in determining that proper rating to be assigned for the Veteran's psychiatric disorder. 38 C.F.R. § 4.14 (2012). The Board finds that the medical evidence of record shows that the Veteran's psychiatric disorder was initially manifested by depression, nightmares, sleep impairment, decreased libido, fear of the dark, anxiety, panic attacks, anger, irritability, hyperactivity, racing thoughts, excessive worrying, easy startlement, and an abnormal mood. The Board finds that those symptoms meet the criteria for an initial rating of 30 percent, as of the date of service connection, but prior to December 13, 2010. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The majority of the Veteran's symptoms are specifically enumerated by the exemplary symptoms listed under the criteria for a 30 percent rating, such as depressed mood, anxiety, panic attacks, and chronic sleep impairment. The Board finds that the evidence of record does not show that the Veteran's psychiatric disorder has been consistently manifested by symptoms which warrant an initial rating of 50 percent of greater. The evidence of record does not show that the Veteran's psychiatric disorder ever resulted in circumstantial, circumlocutory, or stereotyped speech. While the Veteran clearly has impaired memory and cognitive functioning, the medical evidence of record demonstrates that those symptoms are related to her diagnosed brain disorder, not her service-connected psychiatric disorder. Therefore, the evidence of record shows that the Veteran's psychiatric disorder does not result in difficulty in understanding complex commands or impairment of short- and long-term memory. With respect to impaired abstract thinking, the April 2001 VA outpatient mental health note stated that the Veteran's thought processes were tangential. However, tangential thought processes are not analogous to impairment in the ability to think abstractly. In addition, no thought abnormalities were noted in any other medical reports relevant to the period on appeal. Accordingly, the Board finds that the preponderance of the evidence of record shows that the Veteran's psychiatric disorder was not manifested by a thought abnormality which is analogous to that contemplated by a 50 percent rating. The Board finds that the evidence does not show that the service-connected mental disorder causes occupational and social impairment with reduced reliability and productivity as envisioned by the criteria for a 50 percent rating. The Board acknowledges that the Veteran's psychiatric disorder was initially manifested by panic attacks more than once a week as well as disturbances of motivation and mood. However, the Board notes that the Veteran consistently reported that her panic attacks and anxiety decreased significantly in approximately 2001 and 2002, and largely ceased to be a significant concern after that time. In addition, those symptoms alone are not sufficient to warrant an initial rating of 50 percent. In particular, the Board emphasizes that the evidence shows that the Veteran was able to establish and maintain effective relationships. Throughout the entire period on appeal, the Veteran has consistently reported having close friends, having many recreational interests, and being heavily involved in multiple church activities. In addition, the Veteran has had multiple personal relationships throughout the period on appeal, and has consistently maintained employment. While the Veteran has experienced some periods of unemployment, the evidence of record does not demonstrate that any of the periods of unemployment were caused by her psychiatric symptoms, nor that her psychiatric symptoms alone impacted her performance at work in any significant way. The Board finds that such a level of social and work functioning is not analogous to a difficulty in establishing and maintaining effective work and social relationships, as is contemplated by the criteria for a 50 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The Veteran's GAF scores are also consistent with a 30 percent initial rating. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). 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 rating is to be based on all the evidence that bears on occupational and social impairment. 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95 (1995), 60 Fed. Reg. 43186 (1995). In this case, the evidence of record includes only two GAF scores prior to December 13, 2010. In December 2000, the Veteran received a GAF score of 55, which contemplates moderate symptoms, while in March 2001 she received a GAF score of 50, which contemplates serious symptoms. With respect to the Board notes that they included consideration of the Veteran's nonservice-connected cognitive disorder, which causes her impaired memory and concentration symptoms. Therefore, the December 2000 and March 2001 GAF scores represent a level of severity in excess of that caused solely by her service-connected psychiatric disorder. Therefore, the Board finds that the December 2000 and March 2001 GAF scores warrant low probative weight. Accordingly, the Board finds that the manifestations of the Veteran's psychiatric disorder most closely approximate the criteria contemplated for a 30 percent rating under the provisions of Diagnostic Code 9411, for the period prior to December 13, 2010. Upon VA examination on December 13, 2010, a clear decrease in the severity of the Veteran's psychiatric disorder symptomatology was shown. With the exception of cognitive issues which are not for consideration in conjunction with the rating on appeal as they are clearly attributed to a nonservice-connected disability, the only abnormalities noted on examination in December 2010 were tearfulness and a decreased interest in sex. The examiner also assigned a GAF score of 75, which contemplates transient and expectable reactions to psychosocial stressors; with no more than slight impairment in social, occupational, or school functioning. The Veteran herself has repeatedly stated that her symptoms have largely ceased to be a problem. In the December 2010 medical report, she stated that she was fine and had a good friend, her fiancé. Similarly, at the June 2012 hearing before the Board, the Veteran reported that her symptoms were "no big deal as far as [she was] concerned." That evidence of low-level symptomatology is also consistent with the medical evidence dated prior to December 13, 2010. The evidence of record shows that the Veteran ceased receiving regular treatment for her psychiatric disorder in 2001, and complaints of active symptomatology became minimal beginning in 2004. There is no medical evidence of record that the Veteran's psychiatric disability symptoms have increased in symptomatology at any point since December 13, 2010. Accordingly, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's psychiatric disorder, for the period on and after December 13, 2010. Specifically, the Board finds that the evidence does not show that the psychiatric disability caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The Board finds the symptomatology more nearly approximated occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress. This issue has also been reviewed with consideration of whether further staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's psychiatric disorder symptoms, the evidence shows no other distinct periods of time during the period on appeal in which her psychiatric disorder symptoms have varied to such an extent that a rating in excess of those assigned herein would be warranted. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012). Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular evaluation is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for a psychiatric disorder inadequate. The Veteran's psychiatric disorder was rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's psychiatric disorder is manifested by the symptoms listed above. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are contemplated by the disabilities ratings assigned herein for her psychiatric disorder. Ratings in excess of the currently assigned ratings are provided for certain manifestations of psychiatric disabilities, but the medical evidence shows that those manifestations are not present in this case. The criteria for the ratings assigned herein for the Veteran's psychiatric disorder more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the schedular ratings assigned herein are adequate and no referral is required. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.130, Diagnostic Code 9411. In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's psychiatric disorder does not meet the criteria for a rating in excess of 30 percent prior to December 13, 2010, or in excess of 10 percent on and after December 13, 2010. Therefore, the claim for higher ratings beyond those assigned herein is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Seizure Disorder Service connection for a seizure disorder was granted by an March 2011 rating decision and a 20 percent rating was assigned under 38 C.F.R. § 4.124a, Diagnostic Code 8999-8912, effective March 22, 2001. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. Unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and 99. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that an unlisted organic disease of the central nervous system, under Diagnostic Code 8999, was the service-connected disorder, and Jacksonian and focal motor or sensory epilepsy , under Diagnostic Code 8912, was a residual condition. In an April 2000 VA medical report, the Veteran stated that she felt a shocking sensation that day that extended from her right calf to her right ear. On observation, the sensation was characterized by the examiner as a sensory seizure. In a second April 2000 VA medical report, the Veteran stated that she had a seizure the previous week. In an August 2000 VA neuropsychology consultation report, the Veteran reported that she began experiencing sensory seizures approximately once or twice per month, but had few episodes since she started taking Dilantin approximately two years before. The Veteran reported that she had experienced break through seizures, but that they were related to low Dilantin levels secondary to illness. In a September 2000 VA medical report, the Veteran reported experiencing a recent sensory seizure, which was her first seizure since May 2000. She denied having any grand mal seizures. A November 2000 VA seizure clinic note stated that the Veteran was having recurrent partial complex seizures on Dilantin at subtherapeutic doses. She reported that she had experienced approximately two to three sensory seizures per month prior to starting Dilantin, after which they became reasonably well controlled. The Veteran noted two seizure events which had occurred since May. After examination, the diagnosis was partial simple sensory seizures. In a December 2000 VA seizure clinic note, the Veteran reported that she had not had any actual seizures but had experienced some warning signs. In a February 2001 VA outpatient note, the Veteran reported having a seizure aura a few days before which she thought was a partial seizure. In a March 2001 VA seizure clinic note, the Veteran reported that she had only experienced one to two seizures in the previous year. In a January 2002 VA seizure clinic note, the Veteran reported that she had not had any seizure episodes since her previous visit more than six months before. In a March 2002 VA medical report, the Veteran reported that she had experienced a seizure a few days before. She stated that before that she had not had a seizure since April 2000. The Veteran stated that she had been under a lot of stress and had difficulty sleeping. In an addendum, the Veteran stated that it had been one year since she had had a seizure. She denied any symptoms or problems after the seizure, as well as multiple seizures or seizures lasting more than five minutes. In an April 2002 VA women's clinic report, the Veteran reported that her last seizure was in March 2002 and was related to stress and a lack of sleep. A June 2002 VA seizure clinic note stated that the Veteran had been involved in a motor vehicle accident in April 2002, after which her license had been suspended due to a seizure. The examiner stated that the Veteran had never had a generalized tonic-clonic seizure, or any seizure with alternation of consciousness. The note stated that her seizures consisted of a brief sensory electrical phenomena which spread up the right leg and lasted for about five seconds. The seizures were reported to have been successfully treated with low doses of Dilantin. After examination, the examiner stated that it was doubtful whether the Veteran had a seizure at the wheel, as it would not be consistent with her past or recent history. A July 2002 VA neurology note stated that the Veteran had a motor vehicle accident in April 2002. The examiner opined that it was reasonably certain that the Veteran did not have a seizure associated with the accident. The note stated that the Veteran had never had a generalized tonic-clonic seizure, or any seizure with alternation of consciousness. The note stated that her seizures consisted of a brief sensory electrical phenomena which spread up the right leg and lasted for about five seconds. The seizures were reported to be well controlled on Dilantin. In a November 2002 VA miscellaneous neurological disorders examination report, the Veteran reported that she began experiencing various symptoms following a motor vehicle accident in March 1995. She reported that the symptoms recurred until she was given Dilantin by a neurologist, resulting in an abrupt cessation of these episodes. She reported that she had been seizure-free since 2000. In a December 2002 VA seizure clinic note, the Veteran reported that she had not had any seizure activity since her last visit in June. The assessment stated that the Veteran's seizures were all simple partial sensory seizures which were presently controlled with Dilantin. A May 2003 VA seizure clinic note stated that the Veteran had episodes of questionable epileptic origin which consisted of a lightning-like pain shooting through the right leg up to the right ear, lasting for a few second, and without alteration of consciousness. The report stated that the Veteran had never had a definite episode of altered consciousness. In a May 2003 VA outpatient medical note, the Veteran reported that she had experienced a sensory seizure that day, followed by a headache. She reported that the seizure consisted of a shocking sensation which started on the bottom of her right heel and traveled up to her right ear. The Veteran stated that this feeling lasted for 45 seconds and did not result in loss of consciousness. In a June 2003 VA seizure clinic note, the Veteran reported that she had experienced an episode in May, following a decrease in her Dilantin medication. She reported that she subsequently returned her Dilantin dose to the original level. In an August 2003 VA telephone note, the Veteran reported that she had experienced several small seizures that morning, though they did not last very long. In an October 2003 VA seizure clinic note, the Veteran reported that she finished her Dilantin in July, and believed she had an aura shortly afterwards. She reported that she had not had another episode since then. A May 2004 VA seizure clinic note stated that the Veteran had been switched from Dilantin to Lamictal in May 2003. She reported that she was doing well on Lamictal and had not had auras or seizures. A July 2004 VA seizure clinic note stated that the Veteran had initially experienced some break through events with Lamictal, but that after the dose was altered they completely disappeared. A July 2004 VA outpatient medical note stated that the Veteran's last aura occurred in November 2003. An October 2005 VA seizure clinic note stated that the Veteran had previously had breakthroughs of her symptoms on lower doses of medication, but she seemed "well settled" on the present level of medication. A May 2006 VA seizure clinic note stated that the Veteran's medication was reduced at her last visit, and she had tolerated the change without difficulty. The assessment stated that the Veteran was more or less stable. In a December 2006 VA seizure clinic note, the Veteran stated that she had tried to reduce her medication one month before, but found that her symptoms were starting to come back, so she returned the medication to its previous level. The assessment stated that the Veteran apparently needed to remain on her current dose of Lamictal, as lower doses did not stop her shocks. In an April 2007 VA telephone note, the Veteran reported that she had experienced two seizures the previous night, and wanted her medication increased. In a second April 2007 VA telephone note, dated approximately two weeks later, the Veteran reported that she was having seizures in the morning. A May 2007 VA seizure clinic note stated that the Veteran experienced symptoms in April 2007, after which she increased her dosage. She reported that she experience seizures again a day or two later, and then increased her dosage again. A June 2007 VA seizure clinic note stated that the Veteran's symptoms were unusual lightning-like spells which lasted for 10 seconds and spread down her spine into her extremities, with an associated radio-like static noise in her ears. It was reported that they were very short and that the longest ones might last for 15 seconds. The episodes were reported to be responsive to antiepileptic drugs. It was reported that she had an excellent response to Lamictal, but the spells returned following a small drop in dosage, resulting in an increase in dosage to stop the episodes. It was reported that the increased dosage had stopped the episodes successfully. In an October 2007 VA seizure clinic note, the Veteran reported that she was doing very well from a seizure standpoint and had no seizures on her present dose of Lamictal. The impression was possible simple partial seizures. In a December 2007 VA seizure clinic note, the Veteran reported that she had experienced seizures on three different days in late November, all of which were shocking feelings, a hot sensation running up her legs, and the urge to urinate. In an April 2008 VA seizure clinic note, the Veteran reported that she had not had any seizure activity since December 2007. In an August 2008 VA seizure clinic note, the Veteran reported that she had not had any seizure activity since her previous visit. In a November 2008 VA outpatient medical note, the Veteran reported that she had not had any seizures since December 2007. In a January 2009 VA seizure clinic note, the Veteran reported that she had not had any seizure activity since her last visit. In a March 2009 VA seizure clinic note, the Veteran reported that she had not had any seizure activity. In a May 2009 VA seizure clinic note, the Veteran reported that she had not had any seizures. In an August 2009 VA seizure clinic note, the Veteran reported that she had good seizure control with only rare auras. In an October 2009 VA seizure clinic note, the Veteran reported that her last seizure event was several months before, approximately in April, and consisted of a shock through her entire body and then a loud static sound in both ears. She denied any loss of consciousness, though she reported feeling the need to urinate and feeling cold all over. In a May 2010 VA seizure clinic report, the Veteran reported that she had experienced three events in the previous month, with each event lasting approximately 14 seconds. She reported that she was aware of her surroundings with each event, which she described as a "whirling" sensation, feeling very cold, and needing to urinate. The Veteran believed that the events were stress-related. In a December 2010 VA neurological disorders examination report, the Veteran stated that her seizures began with a shock-like sensation traveling up the right or left leg to the ipsilateral arm and hand, followed by an auditory hallucination that sounded like a whirring or radio static. She reported that the episodes lasted about 30 seconds, and denied any loss of consciousness, post-ictal confusion, sensory deficits, or Todd's paralysis. The Veteran reported that the last seizure occurred in April 2010, during a highly stressful period. After physical and diagnostic examination, the diagnosis was simple partial seizures. In a May 2011 VA seizure clinic note, the Veteran reported that she had experienced at least two seizures in the previous year. She described the seizures as a shocking or buzzing sensation in her right ear that went down her neck, followed by feeling very cold and needing to urinate. The Veteran denied any loss of consciousness, and reported that both events lasted from 10 to 15 seconds. Epilepsy, Jacksonian and focal motor or sensory, is rated under Diagnostic Code 8912 which directs that the disability be rated as minor seizures, except in the presence of major and minor seizures, when the disorder should be rated based on the predominating type. 38 C.F.R. § 4.124a, Diagnostic Code 8912 (2012). Under the General Rating Formula for Major and Minor Epileptic Seizures (General Rating Formula), a 10 percent rating is warranted for a confirmed diagnosis of epilepsy with a history of seizures. A 20 percent rating is warranted for at least one major seizure in the last two years, or at least two minor seizures in the last six months. A 40 percent rating is warranted for at least one major seizure in the last six months or two in the last year, or averaging at least five to eight minor seizures weekly. A 60 percent rating is warranted for averaging at least one major seizure in four months over the last year or an average of nine to ten minor seizures per week. An 80 percent rating is warranted for averaging at least one major seizure in three months over the last year or more than ten minor seizures weekly. A 100 percent rating is warranted for averaging at least one major seizure per month over the last year. 38 C.F.R. § 4.124a General Rating Formula (2012). For VA purposes, a major seizure is characterized by the generalized tonic-clonic convulsion with unconsciousness. 38 C.F.R. §4.124a, Diagnostic Code 8911, Note (1) (2012). A minor seizure consists of a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head (pure petit mal), or sudden jerking movements of the arms, trunk, or head (myoclonic type), or sudden loss of postural control (akinetic type). 38 C.F.R. § 4.124a, Diagnostic Code 8911, Note (2) (2012). The ratings assigned for epilepsy are entirely determined by the frequency and severity of the Veteran's seizures. In this case, the Board finds that the preponderance of the evidence of record demonstrates that the Veteran's seizure disorder is manifested by less than five minor seizures weekly and that the evidence does not show major seizures. There is no evidence of record that the Veteran has ever had a major seizure for VA purposes. Specifically, there is no evidence of record that the Veteran has ever had a convulsion of any kind, or loss of consciousness. 38 C.F.R. §4.124a, Diagnostic Code 8911, Note (1) (2012). Accordingly, the Board shall consider the Veteran's various sensory seizures to be minor seizures for VA purposes. 38 C.F.R. § 4.124a, Diagnostic Code 8911, Note (2) (2012). The medical evidence of record includes multiple reports of seizure activity throughout the period relevant to this appeal. As the Veteran clearly does not experience major seizures for VA purposes, for simplicity the Board shall consider all of these reports to be minor seizures for VA purposes, regardless of how they are characterized in the medical evidence. The medical evidence of record shows that the Veteran experienced one seizure in April 2000, one in March 2002, one in May 2003, several in August 2003, one in November 2003, at least three April 2007, three in November 2007, one in April 2009, three in April 2010, and two in the one-year period ending in May 2011. There is no evidence of record that the Veteran ever experienced five or more seizures in any one week period since April 2000. While the evidence of record does not clearly specify the specific number of seizures that the Veteran experienced in August 2003 and April 2007, the description of the events is not such that there appears to have been five or more in any one week period in those months. In addition, those clustered events occurred only twice since April 2000, approximately 13 years ago. Therefore, even if the Veteran did experience five or more minor seizures in August 2003 and April 2007, the frequencies were isolated incidents. As the Veteran's seizures clearly occurred at a rate of significantly less than five in any one week period during the vast majority of the period on appeal, the Board finds that the Veteran's seizure symptoms are not analogous to the criteria contemplated by a 40 percent rating. The Board notes that in a June 2012 hearing before the Board, the Veteran estimated that she would experience about five seizures per day if she were not on medication. The Board accepts the Veteran's estimates as plausible, but the fact remains that she is on medication and as a result does not experience seizures at that frequency. The Schedule only provides ratings based on the number of seizures which actually occur, not on the number which would occur if the Veteran were not receiving treatment. 38 C.F.R. § 4.124a, Diagnostic Code 8911 (2012). In the June 2012 hearing, the Veteran also reported an incident in which she claimed to have experienced 15 consecutive seizures during a trip out-of-state. The Board notes that such a significant number of seizures are not documented at any point from April 2000 to the present. In addition, even if the incident described by the Veteran did occur at some point from April 2000 to the present, it represents an isolated incident which is not representative of the Veteran's overall level of symptomatology. Even if those seizures were added to the list above, the average frequency of seizures would still not meet the criteria for a higher rating. Therefore, the Board finds that a rating in excess of 20 percent is not warranted under the General Rating Formula at any point during the period on appeal. See 38 C.F.R. § 4.124a, General Rating Formula (2012). This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's seizure disorder symptoms, the evidence shows no distinct periods of time when her symptoms have varied to such an extent that a rating in excess of the currently assigned rating would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for a seizure disorder inadequate. The Veteran's seizure disorder was rated under 38 C.F.R. § 4.124a, Diagnostic Code 8912, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's seizure disorder is manifested by less than five seizures weekly. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability rating currently assigned for her seizure disorder. Ratings in excess of the currently assigned rating are provided for certain manifestations of seizure disorders, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned rating for the Veteran's seizure disorder reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. The evidence shows that the Veteran has been employed for the vast majority of the period on appeal, and there is no evidence of record that the Veteran's seizure disorder causes any significant impact on her occupational abilities. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.124a, Diagnostic Code 8912. The Board finds that the preponderance of the evidence is against the claim for an increased rating for a seizure disorder. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert, 1 Vet. App. 49; Massey, 7 Vet. App. 204. ORDER An initial rating of 30 percent, but not higher, for psychiatric disability from March 22, 2001, to December 12, 2010, is granted, subject to the legal authority governing the payment of VA compensation. A rating in excess of 10 percent for psychiatric disability, from December 13, 2010, is denied. A rating in excess of 20 percent for a seizure disorder is denied. REMAND The Board regrets that a remand is again necessary before a decision on the merits of the brain disorder claim can be reached. The Board remanded that claim in September 2011 so that the Veteran could be provided with a VA medical opinion to determine whether her currently diagnosed brain disorder is related to active service. The Board specifically stated that, in the VA examination, the examiner is asked to clearly and directly opine as to whether in-service manifestations of the seizure disorder were at least as likely as not (a 50% or higher degree of probability) manifestations of the leukodystrophy pathology, or whether leukodystrophy is otherwise shown to at least as likely as not (a 50% or higher degree of probability) have manifested or had [its] onset during the Veteran's military service. In March 2012, the Veteran's claims file was referred for an addendum medical opinion. That opinion stated that there was no evidence of clinical or radiographic abnormalities due to Leukodystrophy prior to 1999. There is also no evidence of any condition, illness[,] or exposure, (including seizure disorder) prior to this date that would have caused or contributed to the development [of] the [V]eteran's Leukodystrophy. Therefore, it is NOT at least as likely as not that the [V]eteran's Leukodystrophy/organic brain syndrome began, or was caused by any event during her qualifying active military period. While this addendum provided a generalized etiological opinion, it did not answer the question posed by the Board in September 2011. The examiner did not clearly and directly opine as to whether the Veteran's in-service seizure disorder manifestations were manifestations of her currently diagnosed brain disorder. The Board emphasizes that the lack of any answer to this specific question was the predominant reason for remanding the claim in September 2011. Accordingly, the Board finds that the March 2012 VA medical opinion is incomplete. If VA provides the Veteran with a medical opinion in a service connection claim, the opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the RO did not to provide the Veteran with an adequate VA medical opinion, as requested by the September 2011 Board remand. Compliance with a remand is not discretionary, and if a remand request is not satisfied, another remand for corrective action is required. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination, with an examiner who is a medical doctor and who has not previously examined her, to ascertain the existence and etiology of any brain disorder found. The examiner must review the claim file and should note that review in the report. A complete rationale for the opinion must be provided. Based upon review of the service and post-service medical records, the examiner must provide the following opinions: (a) Does the Veteran have a brain disorder, to include organic brain syndrome and leukodystrophy, that is at least as likely as not (50 percent or greater probability) related to her active duty service or her service-connected seizure disorder, headaches, or psychiatric disorder? (b) Is it at least as likely as not (50 percent or greater probability) that any brain disorder found, to include organic brain syndrome and leukodystrophy, has been aggravated by any service-connected disability? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's in-service seizure symptoms were early manifestations of any subsequently diagnosed brain disorder? (d) If any brain disorder found is attributable to factors unrelated to the Veteran's active service and service-connected disabilities, the examiner should specifically so state. 2. Then, readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _____________________________ ALAN S. PEEVY Veterans Law Judge Board of Veterans' Appeals _____________________________ JACQUELINE E. MONROE Veterans Law Judge Board of Veterans' Appeals _____________________________ HARVEY P. ROBERTS Veterans Law Judge Board of Veterans' Appeals Department of Veterans Affairs