Citation Nr: 1312883 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 09-13 986 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for an acquired psychiatric disorder, to include generalized anxiety disorder and post-traumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1944 to June 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in September 2008 and April 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. In March 2013, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Throughout the pendency of the appeal, the Veteran's acquired psychiatric disorder was manifested by occupational and social impairment with reduced reliability and productivity, due to such symptoms as sleep impairment with frequent nightmares, daily panic attacks, impairment of memory, irritability, hypervigilance, disturbances of motivation and mood, increased isolation and withdrawal, and difficulty in establishing and maintaining effective social relationships, but not occupational and social impairment with deficiencies in most areas, due to such symptoms as 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, spatial disorientation, neglect of personal appearance and hygiene, and inability to establish and maintain effective relationships. 2. The competent evidence of record does not demonstrate that the Veteran's service-connected acquired psychiatric disorder precludes him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. Throughout the pendency of the appeal, the criteria for a disability rating of 50 percent for an acquired psychiatric disorder have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9400 (2012). 2. The criteria for entitlement to a TDIU have not been met. 38 U.S.C.A. §§ 1110, 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions with respect to the issue on appeal. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The information contained in letters dated in September 2007 and March 2009 satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Moreover, the Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the September 2007 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records, VA treatment records, and private treatment records have been obtained and associated with the claims file. The evidence of record includes a March 1989 award certificate from the Social Security Administration (SSA) showing the Veteran was deemed disabled from April 21, 1981 to February 2, 1988. After following all necessary procedures to obtain the information, however, the Veteran's SSA records were deemed unavailable for review in July 2011, and the Veteran was informed of this unavailability. In response, the Veteran asserted that the disability determination was overruled in 2008 and that he was instead receiving retirement benefits through the SSA. As a result, the Board finds the duty to assist the Veteran has been fulfilled with respect to obtaining any additional records from other Federal agencies. In addition, the Veteran was provided VA examinations in September 2008, December 2009, and May 2011 in connection with his claims. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The examiners reviewed the pertinent evidence of record and the Veteran's lay statements and provided sufficient information to decide the issues on appeal. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds the examinations to be sufficient and adequate for rating purposes. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ explained the necessity to submit evidence reflecting the severity of the Veteran's service-connected disability and asked questions to ascertain the history of the Veteran's symptoms or treatment for the disability. In addition, the Veteran was assisted at the hearing by an accredited representative from the Veterans of Foreign Wars of the United States. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his representative. The hearing focused on the elements necessary to substantiate the claim for a higher disability rating, and the Veteran, through his testimony, demonstrated that he had actual knowledge of those elements. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). There is no indication in the record that any additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's claims file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter on appeal. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for that disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV), a global assessment of functioning (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV, American Psychiatric Association (1994), pp. 46-47; 38 C.F.R. §§ 4.125(a), 4.130 (2012). A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 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 51-60 represents 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 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. The Veteran's service-connected disability has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9400, which provides: A 30 percent disability rating is warranted when the Veteran experiences occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when the Veteran experiences 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. A 70 percent disability rating is warranted when the Veteran experiences 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. A 100 percent disability rating is warranted for 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. The Veteran's acquired psychiatric disorder is currently rated as 30 percent disabling for the entire appeal period. Therefore, to warrant a higher disability rating, the evidence must show occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. In an August 2007 written statement, the Veteran stated that he had a nervous breakdown in 1981 as the result of PTSD. He reported that since the breakdown he had problems with frequent nightmares and urination at night. Private medical records dated in May 1981 show an assessment of anxiety and essential hypertension, although the two conditions were noted as not cause and effect. The Veteran was described as extremely anxious, and psychotherapy was strongly recommended. A June 1981 private medical record reflects that the Veteran was driving home after a church meeting when he incurred shortness of breath, palpitations, and dizziness. A notation shows that Doctor Campbell said the condition was due to stress and that the Veteran would need to reduce his stress. The evidence also includes a March 1982 Disability Income Exclusion Form showing Dr. James R. Adams, a clinical psychologist, determined that the Veteran was permanently and totally disabled on May 9, 1981. However, the record does not contain any further information pertaining to the basis for this determination. An October 2007 VA treatment record reflects an assessment of likely PTSD. The Veteran's wife submitted a June 2008 statement in support of his claim. She reported that the Veteran had a complete nervous breakdown in 1981 after having suffered from PTSD for many years. She stated that due to his condition, she was unable to leave his side for one year. The Veteran's wife asserted that he continued to experience the symptoms of his disability. An August 2008 VA treatment record demonstrates an assessment of generalized anxiety disorder rule out PTSD. The Veteran reported a history of nightmares with irritability since active duty and stated that his current chief complaint was anxiety. The Veteran asserted his anxiety remained and that he was limited to being around a certain number of people. He stated that he became very anxious when around his children or other small groups of people. The Veteran denied avoiding situations, re-living active duty, and hypervigilance. The Veteran reported daily nightmares for over 60 years that did not concern the war. He denied anhedonia, decreased appetite, guilt, decreased concentration, and suicidal thoughts. The Veteran also denied recent periods of elevated mood or depression, memory problems, and recent stressors. It was noted that the Veteran had a nervous breakdown in 1981 that involved panic attacks, feeling tired, and being unable to perform his duties as a pastor. The Veteran reported that he had not worked since 1981. On examination, the Veteran appeared much younger than his stated age and was well-groomed and cleanly dressed. He had good eye contact, and he responded appropriately to examination. He understood simple and complex sentences and simple commands and had a moderately rapid rate of speech. His thought process was overinconclusive, and he denied delusions, hallucinations, ideas of reference, obsessions, and suicidal and homicidal ideations. The Veteran's mood was good, his affect was anxious, his judgment was fair, and his insight was fair. The VA physician found the best diagnosis for the Veteran's condition was generalized anxiety disorder. Major depressive disorder was also in the differential because there had been periods where decreased energy and a total lack of ability to work indicated possible depressive episodes. Bipolar disorder was also possible because of an episode of feeling very good before a 1981 nervous break. The VA physician found PTSD was not an easy fit for the Veteran because he did not think about the war very much, even in his nightmares. It was noted that stress from active duty probably predisposed the Veteran to future anxiety despite his prior high functioning. The VA physician found that the Veteran's anxious symptoms were perpetuated by the stressors of unemployment and chronic nightmares and assigned a GAF score of 55. The Veteran underwent VA examination in September 2008 in connection with his claim. The Veteran reported having nightmares involving violence and danger since leaving active duty. Immediately following separation from active duty, the Veteran married, and his wife noted that he had some personality change from before he entered active duty. The Veteran described being irritable, domineering, possessive, and jealous, which continued until 1981, at which time he had a cardiac event. From 1981 to 1989, the Veteran had frequent panic attacks manifested by rapid heart rate, fear of dying, and feeling frozen and unable to communicate. The Veteran retired from his position as a pastor in 1981 when he began to note the anxiety and cardiac symptoms. Mental status examination showed an extremely cooperative, well-groomed man. He was able to give a detailed history, his thought processes were linear, his speech was normal, and there were no psychotic features present. His mood appeared somewhat anxious throughout the interview. He described a marked personality change following active duty from 1946 until 1981, at which time he became a much more emotionally available and less controlling person toward his wife and children. He described daily, residual anxiety, his judgment was intact, and he had good insight. In general, the VA examiner found the Veteran did not endorse symptoms at all compatible with PTSD and diagnosed generalized anxiety disorder, moderate, chronic, and nightmare disorder, chronic, severe. The VA examiner assigned a GAF score of 61 and stated that the Veteran's current social and vocational functioning was significantly limited by his chronic anxiety. He was able to pastor to only a small group of people, and he had to retire from being a pastor to a full congregation in 1981. An additional September 2008 VA treatment record shows the Veteran was still attempting to find acceptable treatment for his diagnosed anxiety, not otherwise specified, rule out PTSD. Sleep and nightmares were noted to be his main concern. In a November 2008 submission, the Veteran stated that his PTSD warranted a higher evaluation based on his symptoms of long-term memory loss, disturbances of mood involving depression and high anxiety, and difficulty in establishing and maintaining effective work and social relationships. The Veteran reported that he could only work a few months or so at any one job and that it took him eight years to slowly establish limited social relationships after his nervous breakdown. He stated that he still had no assurance that he could hold a job. In an April 2009 written statement, the Veteran reported that he had impaired judgment and impaired abstract thinking, which is why he had previously denied avoiding situations, re-living the war, hypervigilance, decreased appetite, lack of enjoyment in pleasurable activities, guilt, decreased concentration, memory problems, and periods of elevated mood or depression. He stated that he did have symptoms of depression, panic attacks, and panic attack nightmares. The Veteran reported that he was unable to participate in group therapy because being around others was too stressful. However, he stated that he had always been open to therapy for his mental health problems, as indicated by his prescription medications. The Veteran underwent additional VA examination in December 2009. He reported having nightmares several times a night that were not military in nature but rather anxiety dreams about performance. He denied flashbacks and suicidal ideations. The Veteran reported insomnia, irritability, avoidance, hypervigilance, and increased startle reaction. He stated that he had poor concentration, decreased appetite, decreased interest in pleasurable activities, dysphoric mood some of the time, and feelings of hopelessness, helplessness, and worthlessness. The Veteran noted that he had two close friends and had been married to his wife for 62 years. He reported a good relationship with his wife but that he had some anxiety whenever his children, grandchildren, and great grandchildren came to visit. The Veteran was cooperative and had normal thought processes. He did not report or appear to have hallucinations or delusions. The Veteran was deemed competent to conduct his activities of daily living. His short-term memory and concentration were both in the below average range, his affect was appropriate but constricted, and his mood was mildly dysphoric. The VA examiner diagnosed generalized anxiety disorder and nightmare disorder and assigned a GAF score of 55. The VA examiner found the Veteran's generalized anxiety disorder interfered with his social interactions with a reduction in the number of people with whom he generally socialized. In support of his claim, the Veteran submitted a self-diagnosis questionnaire. The Veteran reported spontaneous anxiety attacks, the worst of which involved dizziness, heart palpitations, nausea, and a fear of dying. In May 2011, the Veteran underwent additional VA examination in connection with his claim. The Veteran reported spending most of his time on his rural property and having few social activities. At the examination, the Veteran was casually dressed, his speech was spontaneous, coherent, and halting, his attitude was cooperative, his affect was appropriate, and his mood was anxious and dysphoric. The VA examiner found the Veteran was easily distracted but oriented to time, person, and place. His thought processes were somewhat rambling but his thought content was unremarkable. The Veteran had no delusions, his judgment was fair, his insight was limited, and he had average baseline intellectual functioning. He reported symptoms of sleep impairment, to include nightmares, and episodes of increased anxiety with chest pressure. The Veteran denied hallucinations, homicidal thoughts, suicidal thoughts, and episodes of violence. It was unclear whether the Veteran had obsessive or ritualistic behavior, and the Veteran was unable to engage in abstract thinking tasks. The Veteran was deemed able to maintain minimum personal hygiene and had no problems with activities of daily living. The VA examiner also found that the Veteran had some mild impairment with remote memory and moderate impairment with recent and immediate memory. With respect to his specific PTSD symptoms, the Veteran reported recurrent and intrusive distressing recollections of the event and recurrent distressing dreams. He stated that he made efforts to avoid thoughts, feelings, or conversations associated with the trauma and reported hypervigilance and an exaggerated startle response. There was mild impairment in functioning related to symptoms of generalized anxiety and reported posttraumatic symptoms. The Veteran described his symptoms as chronic and reported more difficulty in functioning since his breakdown in 1981. The VA examiner found the Veteran had mild symptoms and diagnosed anxiety disorder, not otherwise specified, with some posttraumatic symptoms; depression, not otherwise specified, secondary to medical conditions; and cognitive disorder, not otherwise specified. The VA examiner found the Veteran met the DSM-IV criteria for a diagnosis of PTSD and assigned a GAF score of 65. The VA examiner found that the changes in the Veteran's functional status and quality of life following his in-service trauma involved his performance in employment and family role functioning. It was noted that the Veteran was able to complete college courses and served as a pastor for 23 years. The VA examiner found the Veteran's symptoms resulted in mild impairment in occupational and psychosocial functioning and that the Veteran's depression secondary to his medical conditions and his cognitive disorder were independently responsible for impairment in his psychosocial adjustment and life quality. The VA examiner opined that there was not total occupational and social impairment due to PTSD signs and symptoms and that the Veteran's PTSD signs and symptoms did not result in deficiencies in areas of judgment, thinking, family relations, work, or mood. The VA examiner found the Veteran did not have reduced reliability and productivity due to his PTSD symptoms, although there was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The VA examiner found the Veteran generally functioned satisfactorily, to include routine behavior, self-care, and normal conversation. The VA examiner also noted that the Veteran continued to live independently and was quite active in his daily routine. Nevertheless, he did experience on-going symptoms of persistent anxiety and worrying with social anxiety and some degree of social withdrawal. The VA examiner opined that the Veteran did not meet the criteria for unemployability due to his service-connected condition. In this respect, the VA examiner noted that the Veteran continued to perform all daily activities of living beyond expectations for his age. The VA examiner found the Veteran was unable to work in an employment situation due to his physical conditions and a decline in cognitive functioning. In May 2012, the Veteran's representative submitted a written statement in support of his claim. The Veteran's representative reported that the Veteran had all the classic symptoms of PTSD, to include nightmares, constant panic attacks, hypervigilance, depression, and deficiencies in both social and occupational areas. The Veteran's representative contended that the Veteran was unable to work as a result of his condition and had very limited social skills. He argued that the Veteran was, for the most part, a recluse with very few friends and that there was tension in his marriage as the result of his irritability and outbursts of anger. The Veteran's representative reported that the Veteran had repeatedly tried to find employment and work with various companies and jobs; however, each time he failed due to stress, anxiety, and his inability to work within a structured environment. The Veteran also submitted a December 2012 private medical assessment and diagnosis signed by a Certified Trauma Services Specialist. On examination, the Veteran was found to have a flattened affect, a mild mood disturbance, and hyperactive motor activity. The Veteran was dressed appropriately and oriented to person, time, and place. His speech functions were slow and tentative, and his speech quality was emotional. The Veteran exhibited poor eye contact, he was cooperative and frank, and his attitude was positive, attentive, and thoughtful. His short- and long-term memory were intact, his level of personal insight was limited, and he was unable to express his current level of distress and combat history without moderate level emoting. The specialist diagnosed PTSD and found the Veteran experienced a clinical level of debilitating capacity to function well on a day-to-day basis. At the March 2013 Board hearing, the Veteran testified that he was currently treating his acquired psychiatric disorder with prescription medication and following an anxiety and phobia workbook. The Veteran reported almost daily panic attacks that sometimes lasted for hours, nightmares, and periods of unprovoked irritability. He reported feelings of detachment and estrangement from others, persistent symptoms of increased anxiety, difficulty concentrating, startling easily, and symptoms of depression. He testified that in the past he was only able to hold down jobs for one to two years due to his symptoms and that his mental health had affected his personal relationships with his friends, family, and wife. The Veteran reported difficulty adapting to stressful circumstances and being overly cautious at all times. He stated that he would check the doors and locks on his home repeatedly every night. The Veteran also reported that there were times when he could not talk to his children at all. He also testified that he had thought about attempting suicide in the past. The Veteran noted that a lot of things made him anxious, and in particular, he avoided watching television. The Veteran and his wife both reported that the Veteran had no social life and that it was too stressful for him to be around people. He was now only able to pastor to 10 to 15 people that he had known for a very long time. The Veteran's wife testified that during the panic attacks and periods of irritability, which occurred almost every day, the Veteran would become withdrawn and silent. She also testified that she often pointed out to the Veteran that he was neglecting his own personal hygiene. Given the above record, the Board concludes that the Veteran's acquired psychiatric disorder was manifested by occupational and social impairment with reduced reliability and productivity. Initially, the Board notes that the Veteran experienced symptoms that are not listed in the rating criteria, and as a result, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with deficiencies in most areas. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Here, the evidence demonstrates that the Veteran's acquired psychiatric disorder was manifested specifically by sleep impairment with frequent nightmares, daily panic attacks lasting up to several hours, some impairment of memory, irritability, hypervigilance, disturbances of motivation and mood, increased isolation and withdrawal, and difficulty in establishing and maintaining effective social relationships. In September 2008, the VA examiner found that the Veteran's current social and vocational functioning was significantly inhibited by his chronic anxiety. Similarly, the December 2009 VA examiner found the Veteran's generalized anxiety disorder interfered with his social interactions with a reduction in the number of people with whom he generally socialized. In addition, the December 2012 private medical assessment reflects the finding that the Veteran experienced a clinical level of debilitating capacity to function well on a day-to-day basis. Furthermore, the Board finds credible the testimony presented by the Veteran and his wife concerning the effect of his symptoms on his ability to perform his duties as a pastor. In this respect, the Board is cognizant that the Rating Schedule is meant to reflect the average impairment of earning capacity resulting from service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Throughout the appeal period, VA physicians assigned GAF scores ranging from 55 to 65, indicating a range of mild symptoms or some difficulty in social and occupational functioning to moderate symptoms or moderate difficulty in social and occupational functioning. Here, the Board finds the Veteran's specific symptoms more often than not align with the symptoms indicated by the lower range of GAF scores assigned. Specifically, the evidence reflects symptoms of flattened affect, daily panic attacks, and difficulty in occupational and social functioning with few friends. Further, the Board finds the effect of the Veteran's symptoms on his social functioning represents more serious impairment based on the analysis presented by the September 2008 VA examiner and December 2012 specialist. Finally, while there were times wherein the Veteran's GAF score improved or worsened, the symptoms manifested remained largely constant. As such, the Board concludes that the evidence as a whole more nearly approximates the criteria for a 50 percent disability rating for the entire pendency of the appeal. 38 C.F.R. §§ 4.7, 4.130 Diagnostic Code 9400. However, the Board finds that a rating in excess of 50 percent is not warranted for the Veteran's service-connected acquired psychiatric disorder. The evidence of record does not reflect occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. The evidence does not show symptoms of 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; spatial disorientation; or neglect of personal appearance and hygiene. The May 2011 VA examiner found the Veteran's symptoms resulted in mild impairment in occupational and psychosocial functioning. The VA examiner found it significant that the Veteran generally functioned satisfactorily, to include routine behavior, self-care, and normal conversation. The VA examiner also noted that the Veteran continued to live independently and was quite active in his daily routine. Further, the evidence demonstrates that the Veteran has been able to maintain a good relationship with his wife for over 60 years and some interpersonal relationships with his family and a small group of people from his church. For these reasons, the Board finds that the criteria for a disability rating of 50 percent, but no higher, for an acquired psychiatric disorder have been met. 38 C.F.R. § 4.130. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service. 38 C.F.R. § 3.321(b)(1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the rating assigned herein inadequate. The Veteran's service-connected acquired psychiatric disorder is evaluated as a psychiatric disability, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.130, Diagnostic Code 9411. During the pendency of the appeal, the Veteran's acquired psychiatric disorder was manifested by occupational and social impairment with reduced reliability and productivity, due to such symptoms as sleep impairment with frequent nightmares, daily panic attacks lasting up to several hours, impairment of memory, irritability, hypervigilance, disturbances of motivation and mood, increased isolation and withdrawal, exaggerated startle response, and difficulty in establishing and maintaining effective social relationships. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are contemplated by a 50 percent disability rating. A rating in excess of 50 percent is provided for certain manifestations of an acquired psychiatric disorder, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for the 50 percent disability rating assigned herein more than reasonably describe the Veteran's disability level and symptomatology, and therefore, the schedular evaluation is adequate, and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). By this decision, the Board has found that a 50 percent rating for an acquired psychiatric disorder is warranted based on the evidence of record for the entire appeal period. However, because the preponderance of the evidence is against the assignment of a 70 percent disability rating, there is no doubt to be resolved, and a rating in excess of 50 percent is not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU In his March 2009 letter, the Veteran reported that he had marked interference with employment since his separation from active duty in June 1946. He argued that his employment from 1946 to 1958 revealed an inability to maintain regular employment responsibilities. Further, the Veteran asserted that as the workload and responsibilities of the pastorate increased from 1958 to 1981, he became totally disabled for any employment. The Veteran stated that when his wife went to work after his retirement, he had attempted to work for people doing house remodeling but had to give that up because it became too stressful. He asserted that regular employment schedule standards were not possible for him to maintain. Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. The Veteran's employment history, his educational and vocational attainment, as well as his particular physical disabilities are to be considered in making a determination on unemployability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Veteran's only service-connected disability is an acquired psychiatric disorder now evaluated as 50 percent disabling. Because the Veteran does not have one service-connected disability rated as at least 60 percent or two or more disabilities with a combined rating of at least 70 percent, with one disability rated at 40 percent, the initial criteria for schedular consideration for the grant of a TDIU under 38 C.F.R. § 4.16(a) are not met. However, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Rating boards are required to submit to the Director, Compensation and Pension Service, for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). Id. Where a veteran does not meet the schedular requirements of 4.16(a), the Board has no authority to assign a TDIU rating under 4.16(b) and may only refer the claim to the Director, Compensation and Pension Service, for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). An assessment for extraschedular referral requires consideration of the veteran's service-connected disability, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b) . The veteran's age and effects of nonservice-connected disability, however, are not factors for consideration. 38 C.F.R. §§ 3.341(a), 4.19 (2012). The issue at hand involves a determination as to whether there are circumstances in this case, apart from nonservice-connected conditions, which would justify a total disability rating based on unemployability. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Board must determine if there is some service-connected factor outside the norm which places the veteran in a different position than other veterans with a 50 percent combined disability rating. Id. The fact that the veteran is unemployed or has difficulty obtaining employment is not enough, as a schedular rating provides recognition of such. Id. Rather, the veteran need only be capable of performing the physical and mental acts required by employment. Id. The schedular criteria contemplate compensating a veteran for considerable loss of working time from exacerbations proportionate to the severity of the disability. See 38 C.F.R. § 4.1 (2012). In this case, the evidence shows that the Veteran has been unemployed since 1981. The Veteran completed six years of college, earning a Bachelor's degree in Theology. Here, the medical evidence of record does not show that the Veteran's service-connected disability, alone, results in unemployability. The May 2011 VA examiner considered the issue of the Veteran's unemployability. The VA examiner found the Veteran's symptoms resulted in only mild impairment in occupational functioning and did not result in deficiencies in the area of work. Although there was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the VA examiner found the Veteran did not have reduced reliability and productivity due to his PTSD symptoms. As such, the VA examiner opined that the Veteran did not meet the criteria for unemployability due to his service-connected condition. In this respect, the VA examiner noted that the Veteran continued to perform all daily activities of living beyond expectations for his age. The VA examiner found the Veteran was unable to work in an employment situation due to his physical conditions and a decline in cognitive functioning, not due to an acquired psychiatric disorder. To the extent that the record shows the Veteran was deemed disabled from April 21, 1981 to February 2, 1988 by the SSA, there is no further evidence demonstrating the basis for such a determination. In addition, the records from 1981 indicate the Veteran suffered from cardiac problems which have not been linked to the Veteran's service-connected disability. As a result, the Board finds that the May 2011 VA examiner's opinion is the most persuasive evidence in this case, which indicates that the Veteran's acquired psychiatric disorder does not preclude him from obtaining or maintaining substantially gainful employment. The VA examiner reviewed the Veteran's claims file for prior medical records of unemployability and examined the Veteran with the issue of whether his acquired psychiatric disorder, standing alone, would preclude employment. The VA examiner concluded that the Veteran was unable to work in an employment situation due to his physical conditions and a decline in cognitive functioning and not due to his service-connected acquired psychiatric disorder. For the reasons stated above, the Board finds that a preponderance of the evidence is against the claim of entitlement to a TDIU, and therefore, there is no doubt to be resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to an initial disability rating of 50 percent, but no more, for an acquired psychiatric disorder is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disability is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs