Citation Nr: 1312958 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 04-03 685 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial evaluation greater than 50 percent for major depression. REPRESENTATION Appellant represented by: Robert V. Chisholm WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from March 1967 to March 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office in Philadelphia, Pennsylvania (RO). The claims file is presently under the jurisdiction of the RO in Cleveland, Ohio. In a January 2012 decision, the Board granted the Veteran's claim for entitlement to an increased initial evaluation for major depressive disorder, and awarded a 50 percent initial evaluation. Subsequently, the Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). Based on a June 2012 Joint Motion for Remand (JMR), in a July 2012 Order, the Court vacated that part of the Board's decision which denied an initial evaluation greater than 50 percent for major depressive disorder, and remanded the claim to the Board for additional reasons and bases. In September 2012, a letter was sent to the Veteran in which he was given 90 days from the date of the letter to submit additional evidence or argument in support of his appeal prior to the Board's readjudication. In October 2012, the Veteran's representative provided additional argument. In February 2013, the Veteran's representative submitted additional evidence and argument, along with a waiver of the Veteran's right to have the RO readjudicate his claim with the additional evidence. See 38 C.F.R. § 20.1304(c) (2012). FINDING OF FACT Since the initial grant of service connection, the Veteran's major depression has been manifested by sleep disturbance, social isolation, depression, nervousness, anxiety, low energy, tearfulness, mild memory trouble, mood swings, crying spells, difficulty adapting to stressful circumstances, feeling overwhelmed, ruminative thoughts, nightmares, flashbacks, anhedonia, avoidance of thoughts and feelings, detachment, irritability, hypervigilance, exaggerated startle response, intrusive thoughts, suspiciousness, and mild memory loss. The medical evidence shows that the Veteran had poor grooming, low mood, flattened or constricted affect, abnormal speech, abnormal psychomotor behavior, normal thought processes, normal thought content, poor judgment, poor insight, and poor eye contact. There was one instance of disorganization to time but normally fully oriented, and infrequent reports of hallucinations. CONCLUSION OF LAW The criteria for an initial rating of 70 percent, but no more, for service-connected major depression have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has certain notice and assistance requirements. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Upon receipt of a substantially complete application for benefits, VA must notify the Veteran of what information or evidence is needed in order to substantiate the claim, and it must assist the Veteran by making reasonable efforts to obtain the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Prior to a readjudication of the Veteran's claim, letters dated in September 2002 and September 2009 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded, Vazquez-Flores v. Shinseki, No. 2008-7150 (Fed. Cir. Sept. 4, 2009); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by the issuance of a fully compliant notification letter followed by a re-adjudication of the claim). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, VA medical treatment records, identified private medical treatment records, and Social Security Administration (SSA) records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In addition, the Veteran was provided with VA examinations with regard to his claim. The Veteran has not indicated that he found any of the examinations to be inadequate. The Board finds that the VA examinations provided in this case are adequate, as they provide sufficient detail to determine the severity of and rate the Veteran's major depression and to issue a fully informed decision on the Veteran's claim. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Finally, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. 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 this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran contends that he is entitled to an initial evaluation in excess of 50 percent for his major depression. By way of history, service connection for major depression was granted by an April 2003 rating decision, and a 30 percent evaluation was assigned, effective August 16, 2002. In October 2003, the Veteran filed a notice of disagreement and filed a timely substantive appeal in January 2004. In August 2005, the Board remanded the Veteran's claim for additional development. By an April 2006 rating decision, the RO proposed to reduce the Veteran's rating, and in a September 2006 rating decision, the RO reduced the evaluation for major depression to 10 percent, effective December 1, 2006. A January 2009 rating decision restored the 30 percent rating for major depression, effective December 1, 2006. Although a July 2010 rating decision confirmed and continued a 10 percent evaluation, a November 2010 supplemental statement of the case confirmed and continued the 30 percent initial rating for major depression. By a January 2012 decision, the Board awarded an initial evaluation of 50 percent for the Veteran's major depression. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating 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; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. 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; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as here, a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence 'used to decide whether an initial rating on appeal was erroneous . . . .' Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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. Id. The Veteran is currently assigned an initial disability rating of 50 percent for major depression under Diagnostic Code 9434. A 50 percent disability rating is contemplated for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent disability rating is contemplated for 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is contemplated 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 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. Id. GAF scores are a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), p. 32). GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 and 70 reflect 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. Scores ranging from 51 to 60 reflect more 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). Scores ranging from 41 to 50 reflect 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). Scores ranging from 31 to 40 reflect 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 other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. Initially, the Board observes that the Veteran's medical records reflect a nonservice-connected diagnosis of posttraumatic stress disorder (PTSD). However, most of the medical records have not specifically indicated what symptoms are attributable only to the nonservice-connected disability. Thus, the Board will, for the limited purpose of this decision, attribute all psychiatric signs and symptoms to the Veteran's service-connected major depression. See Mittleider v. West, 11 Vet. App. 181 (1998) (finding that when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition). VA treatment records from August 2001 note the Veteran's complaints of sadness and stress due to problems with a supervisor at work. He indicated that he was married for the prior 16 years, but that he was estranged from his wife with whom he resided. He also noted that he had little contact with his three siblings. Mental status examination showed the Veteran to have normal grooming. He was casually dressed and nervous, but cooperative. His mood was sad and nervous, and his affect was flattened. Speech was normal. There was abnormal psychomotor behavior, as the Veteran spent the entire session scratching himself on the arms, legs, and head. The Veteran stated that he was scratching because he was feeling nervous. Thought process was coherent with some difficulty describing experiences. Thought content was normal. Judgment was poor, but the Veteran was fully oriented. A GAF score of 55 was assigned. A January 2002 record notes the Veteran's history of depression and alcohol dependence. In August 2002, the Veteran stated that he felt down and needed help with his nerves and stress after quitting his job for the postal service due to back pain. Mental status examination showed the Veteran to be alert and fully oriented. He had fair grooming and hygiene, but some difficulty answering questions. There was an absence of facial expression and poor eye contact. Speech appeared slowed and affect was very bland. The Veteran was inappropriate to the depressive content of his thoughts. Perceptions were normal, and the Veteran denied audiological and visual hallucinations. He was unable to perform serial sevens and had minimal insight and judgment. The Veteran noted a recent depressive episode after quitting his job. He reported that he lived with his wife of 15 years, but noted that they rarely spoke except to argue. He indicated that he spent most of his time in a separate room and felt as if they were separated although living together. He stated that he had one adult daughter with whom he had a dispute six months before, and no longer had contact with. He reported that he had no other social supports and spent most of his time alone. A GAF score of 51 was assigned. An October 2002 record reflects that the Veteran complained of trouble with his nerves and depression. He noted difficulty sleeping, poor appetite, and low energy. He also stated that he was in the process of getting a divorce. He indicated that he worked the graveyard shift as a postal worker. He denied suicidal ideation and psychosis. Mental status examination showed the Veteran to be cooperative and casually dressed with fair grooming and hygiene. Speech was normal and mood was not so good. Affect was constricted. There was no suicidal or homicidal ideation, or hallucinations. Thought form was organized and goal-directed, and cognition was intact. A GAF score of 50 was assigned. In December 2002, the Veteran underwent a VA psychiatric examination. The Veteran complained of depression, isolating behavior, self-deprecating thoughts, and tearfulness. He also noted insomnia, decreased interest, feelings of helplessness, poor energy, poor concentration, and some psychomotor retardation. He denied difficulty with appetite as well as suicidal or homicidal ideation. He also denied psychotic symptoms, but admitted to anxiety. He denied panic attacks but acknowledged social isolation. The Veteran indicated that he was married for the prior 18 years, but that his marriage was "on paper only," as it was bad for the prior 17 years. He indicated that he and his wife slept in separate rooms and did not eat together or speak. He noted that he had no regular contact with his siblings and no close relationships with neighbors, high school friends, or military friends. He indicated that he did maintain some friendships with coworkers. He stated that he had a daughter from another relationship with whom he had no contact. He reported that his activities included mostly solitary activities, and that he enjoyed watching the history channel on television. He also noted that he enjoyed lawn work and golf, but that he was unable to participate in those activities due to pain. He also noted that he has worked as a postal clerk for the prior 18 years, and that he was working the third shift. He indicated that he missed time from work due to back pain, and that his employer was angry with his limited work capacity and time missed. He described a long history of alcohol dependence. Mental status examination revealed the Veteran to be neatly dressed and well-groomed. Speech was slow and there was evidence of paucity of speech as well as latency. Speech was also low in volume. He appeared to have some slowing of cognitive processes. He was alert and fully oriented, and memory was intact. Eye contact was very poor. Mood was depressed and somewhat anxious, and affect was congruent. There was no evidence of any formal thought disorder, and the Veteran denied hallucinations and paranoia. He also denied suicidal and homicidal ideation. Insight and judgment were limited or poor. A GAF score of 55 was assigned. The examiner indicated that the Veteran had moderate to severe symptoms with difficulty in social and occupational functioning. He reported very few friends and a nonexistent relationship with his wife. He also indicated that he missed an average of a quarter of his time from work due to chronic pain and resulting depression. October 2003 private records reflect that the Veteran was admitted to the hospital following heavy drinking, depression, and talk of suicide. On admission, the Veteran denied feeling depressed, but admitted to feeling sad after the loss of a friend. He denied suicidal ideation, delusions, and hallucinations. He was oriented to person and place, but partially disorganized to time and had a lot of difficulty concentrating. During his admission, he reported having hallucinations; thereafter, his psychiatric medicine was increased. He continued to improve, and was discharged approximately nine days after admission. A December 2003 private record indicates that the Veteran's nerves were acting up and that he felt depressed. Examination showed him to be shaky with a depressed affect. December 2003 VA treatment records reflect that the Veteran was treated for alcohol detoxification. The records indicate that the Veteran was neatly attired and covered his face and closed his eyes. Speech was normal without evidence of formal thought disorder. Mood and affect were dysphoric. The Veteran noted that he was married and that his wife supported him financially, but indicated that they did not get along. The Veteran also complained of frequent anxiety. A GAF score of 45 was assigned. Treatment records beginning in 2004 show that the Veteran began attending group therapy for depression and alcohol abuse. The records note that the Veteran reported symptoms including fatigue, and poor sleep. In April 2004, the Veteran complained of stress related to work and having bad thoughts. He denied any urges to harm himself but states that he was not handling the stress well. He noted a heavy mood, lack of energy, and problems with sleep. Mental status examination revealed the Veteran to be neat, cooperative, and pleasant with psychomotor retardation. There was substantial delay in responding to questions. Information given was vague. Mood was described as heavy, and affect was constricted. Thoughts were logical and there was no suicidal or homicidal ideation. There were no hallucinations or paranoia. Insight was limited and judgment was fair. SSA records reflect that the Veteran was found to be disabled, effective October 2003, based upon diagnoses of degenerative disc disease and posttraumatic stress disorder. The records indicate that the Veteran retired from his job with the U.S. postal service in 2003, after 18 years of employment, due to health issues. The records upon which the SSA decision was based were primarily VA treatment records from 2002 through 2004. In an October 2004 statement to the SSA, the Veteran reported that he sometimes experienced difficulty with personal hygiene and grooming, and noted that sometimes his wife had to remind him that his grooming had been neglected. He also noted that he had problems with other people in authority, stating that he wanted to harm a supervisor due to disrespect, lack of trust, unfair treatment, and harassment. Additionally, he described memory trouble. A November 2004 psychiatric assessment indicates that the Veteran could perform the activities of daily living independently. The assessment notes that the Veteran's cognitive functioning was sufficient, and he could concentrate on simple tasks and make basic work-related decisions. He could sustain superficial or occasional interactions with others. Depression with irritability limited his ability to work with the public frequently, and a nonpublic setting with minimal social demands would be preferable for him. In August 2004, the Veteran underwent a VA psychiatric examination. The Veteran reported that he had not worked in the prior eleven months due to unstable and ongoing back pain. The examiner noted that the Veteran appeared to have some difficulty understanding some of the examiner's questions. He complained of decreased energy, nervousness, anger, mood swings, and feeling like he was in a rut. He also reported difficulty sleeping and chronic pain throughout his body. Mental status examination revealed the Veteran to have fair eye contact. His speech was deliberate with some hesitancy. He was casually dressed and his affect was constricted. The examiner noted some deficits in his remote recall as well as mild concentration difficulty and some hesitancy in answers. Insight was poor and judgment was fair. The Veteran admitted to have crying spells on occasion. There was no evidence of hallucinations or delusion. The Veteran denied suicidal and homicidal ideation, but he claimed that, while at work, he had some thoughts of doing harm to people who were not supportive of him. There was no evidence of obsessive or ritualistic behaviors other than staring out the window on occasion. There were no symptoms of panic or excessive anxiety. The Veteran did not report having routine hobbies or routine visits by friends. He reported a constricted social life and indicated that his grandchildren did not visit him frequently. A GAF score of 55 was assigned. During a May 2005 hearing before the Board, the Veteran testified that his symptoms included difficulty adapting to stressful circumstances, trouble focusing, difficulty coping with the future, continuous depression, thoughts of suicide, poor relationship with his wife, and social isolation. VA treatment records from 2005 and 2006 note the Veteran's complaints of depression, poor sleep, crying, poor energy, poor concentration, nervousness, anxiety, difficulty focusing, and lethargy. In April 2006, the Veteran underwent a VA examination. He described symptoms including depression, poor sleep, sad mood, and difficulty sleeping. He indicated that he had been married for 20 years, but that he and his wife just lived together and had no real relationship. He noted occasional suicidal thoughts and feeling overwhelmed. He indicated that he used to enjoy going to sports events, and now he sometimes watches them on television. He described a very inactive routine with lack of motivation. Mental status examination revealed the Veteran to have good eye contact. He was alert and fully oriented, and his psychomotor activity was normal. He was casually dressed and groomed, and his speech was clear and of normal volume and articulation. His affect and mood were congruent. Thought process was goal-oriented with no derailment, loose, or changing associations. There was no sign of delusional or frankly paranoid belief systems and no current suicidal ideation. A GAF score of 60 was assigned, and the examiner noted that the Veteran's mental health problems had a moderate impact on his ability to function. A July 2006 VA examination notes that the Veteran denied hobbies except for watching sports on television. The examiner indicated that the Veteran appeared to depend on his wife for managing bills, household chores, and cooking, but that he thought he was capable of helping. He noted that he talked to his daughter occasionally. Mental status examination showed the Veteran to be appropriately and casually dressed. He was alert and showed intermittent reasonably good eye contact, but was somewhat malodorous. He appeared sluggish, wrung his hands, responded slowly to questions, and had difficulty understanding the intent of the questions. He frequently produced impoverished and confused answers. His psychomotor activity was slowed below normal. His speech was often delayed, halting, and poorly pronounced. His affect was flat, sad, and minimally expressive. His thought process was goal-oriented and without loose or changing associations. There were no signs of delusional or paranoid belief systems, however, he did describe hallucinatory experiences and delusional content. He was depressed and anhedonic, had poor motivation, varied appetite, apathy, agitation, slowed motor activity, fatigue, reduced self-esteem, and poor concentration. There was no evidence of suicidal ideation. The Veteran reported poor sleep due to pain and ruminative thoughts. He expressed no symptoms or history of mania. He felt nervous and fearful much of the time, and sometimes felt shaky with butterflies or an increased heart rate. When asked about his psychosis symptoms, he said that he saw spots of light that circled around his head and thought aliens might be causing the phenomenon. He generally felt people were against him and might have intention to harm him. He had mild ideas of reference regarding the television ad other personal events. He denied auditory hallucinations and frank paranoid ideas of reference, special messages, thought broadcasting, and special powers. A GAF score of 40 was assigned. The examiner noted that the Veteran's depression appeared to be much worse than his pain in the prior several months, with symptoms including rumination. VA treatment records from 2008 reveals the Veteran's reported symptoms of nightmares, flashbacks, stress, alcohol abuse, anxiety, avoidance of thoughts and feelings, anhedonia, detachment and emotional numbing, sense of foreshortened future, irritability, concentration difficulty, hypervigilance, and exaggerated startle response. A May 2008 record reveals a GAF score of 40. In June 2008, the Veteran indicated that he was in contact with his one biological daughter. In July 2008, the Veteran was casually dressed with good hygiene. His mood was described as "getting by" and his affect was sad and flat. He was open and cooperative with little insight. He was alert and fully oriented with no eye contact. Speech was tremendously slowed, and he seemed to lose sight of the question several times. There was a noticeable tremor in his left arm during the interview. The Veteran reported feeling down and indicated that he did not like being around people. He noted that he was nervous and scared around others, and that he did not call his daughter due to nervousness and fear. He again stated that, although married, he did not have a relationship with his wife. He described visual hallucinations of lights that circled around his head, and noted that he thought that the lights might be aliens. He denied auditory hallucinations. A GAF score of 40 was assigned. A September 2008 record indicates that the Veteran was neatly groomed with good hygiene. His mood was "not so bad" and his affect was appropriate and full-range. He was open and cooperative with moderate insight. The Veteran made more eye contact than normal, was more engaging, and talked at length about session topics. In October 2009, the Veteran underwent another VA examination. The Veteran reported symptoms, including fatigue, sadness, poor sleep, irritability, and social isolation. He noted that he experienced all of those symptoms for a number of years at the current level of intensity. He was tearful during the examination. The Veteran was retired from his job at the U.S. postal service, and was not working. He stated that he did not have any hobbies or regular social contacts. He described a distant relationship with his wife, and stated that he did not have any contact with friends. He rated his current intensity of sadness as a 7 out of 10, which he experienced on a daily basis. He reported impaired sleep and irregular appetite. He noted that, a couple of times in the past year, he held a conversation with someone who wasn't there, and indicated that he thought that he had a visitor. He also endorsed symptoms of intrusive thoughts, nightmares, avoidance of trauma-related stimuli, irritable mood, and exaggerated startle response. He indicated that he participated in treatment for a number of years, but did not experience significant relief from symptoms. Mental status examination revealed the Veteran to be alert and fully oriented with appropriate grooming. Eye contact was not consistently maintained throughout the interview, and the Veteran often closed his eyes when speaking or had his hand to his face. The Veteran's range of affect was constricted and his mood was depressed. Speech was at a slow rate and below average volume. He often answered questions after significant delay and with slow speech, although his thoughts were generally logical and understandable. He denied suicidal ideation, but endorsed a history of fleeting suicidal ideation in the past. The examiner concluded that the Veteran's symptoms were significant with severely limited social contact and limited engagement in meaningful activities. The examiner did not believe that there was sufficient evidence to conclude that the Veteran experienced psychotic symptoms. A GAF score of 41 was assigned. In a November 2010 statement, the Veteran's wife reported that the Veteran was stressed and depressed, had extreme mood swings, and lacked positive self esteem. She noted that the Veteran changed his grooming habits from showering, brushing his teeth, combing his hair, and putting on clean clothes to wearing the same pajamas daily. He laid in bed for most of the day watching television or sleeping, and took his food to the bedroom to eat alone. Rather than going to the bathroom to urinate, he used a urinal in the bedroom. She noted that the Veteran frequently tells her to leave him alone. She stated that their house was dark because the Veteran did not want the curtains open and that he claimed that he was being watched. She noted that he sometimes banged on the walls with his fist, denting the dry wall. She reported that the Veteran lacked the desire to complete routine chores, and that she did most of the house work. She also stated that the Veteran alienated himself from friends and most family members, and that he wanted her to do the same. She noted that he does not answer the telephone or door, even when his daughter or grandchildren called. She related the Veteran's odd behaviors, noting that the police found the Veteran sleeping in his car on the railroad track at 2:00 a.m. with the ignition on, and often forgetting to close the garage door. During a September 2011 hearing before the Board, the Veteran testified that his symptoms included depression, crying spells, lack of motivation, and trouble concentrating. He noted that he was verbally abusive and did not like being bothered by his grandchildren anymore. He reported social isolation, lack of friends, worsening relationships with family, confusion, hopelessness, and tearfulness. In February 2012, the Veteran underwent another VA psychiatric examination. The Veteran reported that he was married, but that his wife did not live with him full-time and that he did not know nor care where else she lived. He noted that his wife accused him of being verbally abusive. He stated that he had one friend who came to his house occasionally. He denied all other social activities and hobbies. The VA examiner reported that the Veteran had symptoms including: depressed mood, anxiety; suspiciousness; chronic sleep impairment; mild memory loss; flattened affect; speech intermittently illogical, obscure, or irrelevant; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; suicidal ideation; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living. The examiner noted that the Veteran also had intrusive memories, nightmares, distress at exposure to cues, avoidance, feeling detached from others, irritability, anger, hypervigilance, and exaggerated startle response. The examiner reported that the Veteran presented in wrinkled and dirty clothing, was malodorous, and seemed to have poor hygiene. The Veteran seemed distracted and had difficulty focusing to answer questions. He made little eye contact and had a restricted range of affect and anxious or irritable mood. Thought process was illogical and vague, and at times he showed poverty of speech. Thought content did not seem to include hallucinations or frankly paranoid or delusional symptoms, but it was difficult for the examiner to determine based on the Veteran's vague and illogical answers. The examiner concluded that it was likely that the Veteran's major depressive disorder rendered him unable to secure or follow a substantially gainful occupation. The examiner concluded that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. A GAF score of 38 was assigned. In a February 2013 letter, E. Calandra, M.A., CCM, CDMS, concluded that the Veteran's service-connected disabilities resulted in his inability to secure and/or follow a substantially gainful occupation since August 2002. The Veteran's current 50 percent evaluation contemplates 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, Diagnostic Code 9434. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF scores of 38 and 40 show some impairment in reality testing or communication or a major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. The Veteran's GAF scores of 41, 45, and 50 reflect serious symptoms or any serious impairment in social, occupational or school functioning. The GAF scores of 51, 55, and 60 reflect more moderate symptoms or moderate difficulty in social, occupational, or school functioning. Thus, the Veteran's GAF scores indicate that his psychiatric symptoms ranged from moderate to very serious, reflecting impairment in reality testing or communication or major impairment in several areas of his life. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is considered but is not determinative of the percentage VA disability rating assigned; the percentage evaluation is based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). Based on the analysis of the evidence as outlined below, the Board finds that the evidence supports an initial rating of 70 percent, but not greater, for the Veteran's service-connected major depression. Since the initial grant of service connection, the Veteran reported symptoms including constant depression, anxiety, nervousness, severe social isolation, poor sleep, low energy, tearfulness, memory difficulty, mood swings, crying spells, poor concentration, difficulty focusing, ruminative thoughts, nightmares, flashbacks, anhedonia, and irritability. He also reported difficulty adapting to stressful circumstances, feeling overwhelmed, avoidance of thoughts and feelings, detachment or emotional numbing, hypervigilance, exaggerated startle response, intrusive thoughts, verbal abuse, and suspiciousness. The Veteran's wife noted that the Veteran had poor hygiene and grooming. Additionally, the Veteran described a lack of any meaningful relationships in his life, noting that he was estranged from his wife even though living with her, he had little to no contact with his daughter or siblings, and he had no friends or other social support system. The medical evidence shows that the Veteran was sad, nervous, depressed, anxious, and dysphoric with a flattened, constricted, dysphoric, sad, or minimally expressive affect. His speech was frequently irregular, described as illogical, obscure, or irrelevant, slowed, with paucity and latency, low in volume, deliberate but hesitant, delayed, halting, and poorly pronounced. Abnormal psychomotor behavior or psychomotor retardation was noted on several occasions. Judgment was poor, minimal, limited, fair, or impaired, and insight was minimal, limited, or poor. The Veteran was usually alert and fully oriented, although on one occasion he was disorganized to time. Grooming and hygiene were noted as normal or fair on some occasions, and impaired on other occasions. Eye contact was regularly poor or very poor, but on occasion was good or fair. The medical evidence reflects that the Veteran occasionally admitted to auditory and visual hallucinations, but denied them in most instances. There is also evidence of suicidal ideation, but no plan or intent. There is no evidence of homicidal ideation. The Veteran's symptoms were described by his physicians and the VA examiners as moderate to severe with difficulty in social and occupational functioning; significant with severely limited social contact and limited engagement in meaningful activities; inability to establish and maintain relationships with an intermittent ability to perform the activities of daily living; and deficiencies in most areas. Further, the most recent VA examiner found that the Veteran was unable to secure or follow a substantially gainful occupation as a result of his major depression. With consideration of the entire record, the Board finds that the evidence shows that the Veteran's major depression more nearly approximates the criteria for the next higher disability rating of 70 percent since the initial grant of service connection. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9434. The evidence shows suicidal ideation; speech intermittently illogical, obscure, or irrelevant; near-continuous depression affecting the ability to function independently, appropriately, and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and an inability to establish and maintain effective relationships. While all symptoms listed for a 70 percent evaluation are not shown, the criteria are simply guidelines for determining whether the Veteran meets the dominant criteria. The dominant criteria for a 70 percent evaluation are occupational and social impairment, with deficiencies in most areas. In this case, the evidence of record demonstrates that this was met. Accordingly, based on all the evidence of record, the manifestations of the Veteran's major depression meets the criteria contemplated for an initial 70 percent evaluation under the provisions of Diagnostic Code 9434. However, the evidence shows that the Veteran's major depression does not meet the criteria for the next higher disability rating of 100 percent. 38 C.F.R. § 4.130, Diagnostic Code 9434. In that regard, although there is evidence of intermittent inability to perform activities of daily living and one instance of disorientation to time, there is no evidence of gross impairment in thought processes or communication; grossly inappropriate behavior; or memory loss for names of close relatives, own occupation, or own name. While there was evidence of some auditory and visual hallucinations, the medical evidence does not show them to be persistent. Further, although the Veteran reported suicidal ideation, there was no evidence of plan or intent; thus, the evidence does not indicate that he was in persistent danger of hurting himself or others. Ultimately, the Board finds that the evidence of record does not show that the Veteran's symptoms of major depression cause total social and occupational impairment sufficient to warrant a 100 percent rating. In other words, the Veteran's symptoms do not rise to the level of functioning suggested by the symptoms described in a 100 percent evaluation. Accordingly, as the evidence does not show total occupational and social impairment, the Veteran's symptoms do not meet the criteria for a 100 percent evaluation for major depression. 38 C.F.R. § 4.130, Diagnostic Code 9434. The Board has also considered the Veteran's symptoms which are not specifically contemplated by the Rating Schedule, such as sleep disturbance, social isolation, low energy, tearfulness, mood swings, crying spells, poor concentration, difficulty focusing, feeling overwhelmed, nightmares, flashbacks, anhedonia, avoidance of thoughts and feelings, detachment or emotional numbing, irritability, hypervigilance, exaggerated startle response, intrusive thoughts, and suspiciousness. While those symptoms certainly contribute to the impairment caused by the Veteran's major depression, they do not show total occupational and social impairment sufficient to warrant a 100 percent evaluation. Mauerhan, 16 Vet. App. 436. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). 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 Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's major depression is not so unusual exceptional in nature as to render the rating for this disorder inadequate. The criteria by which the Veteran's major depression is evaluated specifically contemplate the level of impairment caused by that disability. Id. As demonstrated by the evidence of record, since the initial grant of service connection, the Veteran's major depression has been manifested by sleep disturbance, social isolation, depression, nervousness, anxiety, low energy, tearfulness, mild memory trouble, mood swings, crying spells, difficulty adapting to stressful circumstances, feeling overwhelmed, ruminative thoughts, nightmares, flashbacks, anhedonia, avoidance of thoughts and feelings, detachment, irritability, hypervigilance, exaggerated startle response, intrusive thoughts, suspiciousness, and mild memory loss. The medical evidence shows that the Veteran had poor grooming, low mood, flattened or constricted affect, abnormal speech, abnormal psychomotor behavior, normal thought processes, normal thought content, poor judgment, poor insight, and poor eye contact. There was one instance of disorganization to time but normally fully oriented, and infrequent reports of hallucinations. When comparing this with the symptoms contemplated in the Rating Schedule, the Board finds that the schedular evaluation regarding the Veteran's major depression is not inadequate. An evaluation greater than 70 percent is provided for certain manifestations of major depression, but the medical evidence reflects that those findings are not present in this case. Therefore, the schedular evaluation is adequate and no referral is required. The Board acknowledges that there is evidence that the Veteran's major depression results in an inability to secure or follow substantially gainful occupation. However, as the schedular evaluation is adequate in this case, that finding is not sufficient to support referral for an extraschedular evaluation. Thun, 22 Vet. App. at 115. Additionally, although the Veteran has raised the issue of entitlement to a total disability evaluation based on individual unemployability (TDIU) and has submitted new evidence in support of that claim, the issue of entitlement to a TDIU was remanded by the Board in January 2012, and that portion of the Board's January 2012 decision was not disturbed by the Court's July 2012 Order granting the JMR. Thus, that issue is currently before the RO, and the Board does not have jurisdiction over it at this time. See Rice v. Shinseki, 22 Vet. App. 447 (2009). After review of the evidence of record, there is no evidence of record that would warrant a rating in excess of 70 percent for the Veteran's service-connected major depression at any time during the period pertinent to this appeal. 38 U.S.C.A. 5110 (West 2002); see also Fenderson, 12 Vet. App. at 126. While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected major depression, the evidence shows no distinct periods of time since service connection became effective, during which the Veteran's major depression has varied to such an extent that a rating greater or less than 70 percent would be warranted. Cf. 38 C.F.R. § 3.344 (2012) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). ORDER An initial evaluation of 70 percent, but no more, for major depression is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs