Citation Nr: 1315167 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 09-27 636 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for generalized anxiety disorder. 2. Entitlement to service connection for a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: Robert V. Chisholm, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Helena M. Walker, Counsel INTRODUCTION The Veteran served on active duty from December 2000 to December 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal of a January 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which granted a 30 percent rating for the Veteran's anxiety disorder. In an October 2010 decision, the Board awarded a 50 percent rating for the Veteran's anxiety disorder. This award was made effective September 30, 2008, (the date of the claim for increase) in a November 2010 rating decision. The Veteran appealed the rating to the United States Court of Appeals for Veterans Claims (Court). In March 2012, the Court issued a Memorandum Decision (single judge) setting aside the October 2010 Board decision that increased the Veteran's rating for anxiety disorder to only 50 percent disabling. It remanded the claim for action consistent with its decision. In addition to a paper claims file, the Veteran also has an electronic file known as a Virtual VA file. The Board has reviewed both the paper and electronic record associated with the Veteran's claim. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's anxiety disorder is manifested by symptoms such as depression, irritability, panic attacks, concentration and memory problems, and some impairment of relationships with others, reports of suicidal ideation, and difficulty adapting to stressful situations, all resulting in deficiencies in most areas, but less than total social and occupational impairment. CONCLUSION OF LAW The criteria for a disability rating of 70 percent, but no higher, for anxiety disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9400 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Although the Board has an obligation to provide reasons and bases supporting this decision, 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) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA). 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). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO's October 2008 and March 2009 letters advised the Veteran of the necessary elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Specifically, the RO's October 2008 letter informed the Veteran of what evidence was required to substantiate his claim for increased disability ratings and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence or information in his possession to the RO. See Vazquez-Flores v. Shinseki, 580 F. 3d 1270 (Fed. Cir. 2009). 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, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In addition, the duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as his identified VA and private medical treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also provided the Veteran with multiple medical examinations to determine the severity of his mental disorder. 38 C.F.R § 3.159(c)(4). The Board also finds that the VA examination obtained in this case is more than adequate, as it was based upon a physical examination of the Veteran, a review of his claims file, and with consideration of the Veteran's statements. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In addition, the Veteran has submitted a private psychological report describing his symptoms and the impact his anxiety disorder has on his social and occupational functioning. Finally, there is no indication in the record that additional evidence relevant to the issue 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, 20 Vet. App. 537 (2006). Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). 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 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). The Rating Schedule establishes a general rating formula for mental disorders. 38 C.F.R. § 4.130 (2012). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). Id. Service connection for the Veteran's generalized anxiety disorder was granted by a June 2005 rating decision and a 10 percent evaluation was assigned under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9400, effective from December 20, 2004. See 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). The Veteran filed his present claim for an increased evaluation for his service connected generalized anxiety disorder in September 2008. In a January 2009 rating decision, the RO increased the evaluation to 30 percent evaluation for his generalized anxiety disorder. The Veteran filed a timely notice of disagreement in February 2009 and perfected his appeal in July 2009. As noted above, the Board granted a 50 percent rating in its October 2010 decision, and the RO assigned an effective date in September 2008. He appealed this rating to the Court, which set aside the Board's October 2010 decision and remanded it to the Board for action consistent with the Memorandum Decision. Pursuant to Diagnostic Code 9400, generalized anxiety disorder is rated 30 percent when it is productive of 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, or mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted when there is 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 evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is objective evidence demonstrating 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. In evaluating the evidence, the Board has noted the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DSM-IV; Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, such as occasional truancy, or theft within the household, but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 41 to 50 is assigned where there are 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). DSM-IV at 46-47. Factual Background and Analysis An October 2008 VA psychiatry consultation report stated that the Veteran was seen after an emergency room visit for anxiety. The Veteran stated since his return from Iraq in December 2004 to January 2005, he noted increasing anxiety. He gave a history of psychiatric treatment in service and trying multiple medications without relief of symptoms. The Veteran was currently using marijuana to help control severe anxiety. The Veteran related that since his return from Iraq, he had multiple stressors in his personal life. He attempted to work, but lost jobs because of his anxiety and inability to concentrate and stop shaking. The Veteran also gave a history of childhood trauma where his cousin died in his arms after being hit by a homemade bomb that they made together when the Veteran was 16 years old. It was noted that the childhood trauma was compounding experiences from his time in Iraq. The Veteran reported depression, disturbed sleep, decreased appetite due to nervous stomach, decreased concentration with ruminating and racing thoughts, increased guilt over not providing for and not having contact with his daughters, and feeling hypersexual. He related that he had mild anxiety prior to going to Iraq, which had increased since the time there and being back. He would have panic attacks during which he would experience difficulty breathing, inability to think, and racing heart, and become diaphoretic. He stated that he needed to have a routine because not having a routine made him anxious. He recalled a recent event where he climbed the rock-climbing wall at a sporting goods store and could not get down because his legs were shaking very bad. He also reported sleepwalking tendency, feeling tense all the time, nightmares, flashbacks, and avoidance of things that reminded him of time in Iraq, to include avoiding the people from the Corps. He reported that he last worked in a customer service job for 9 months, but lost the job due to constant anxiety and decreased concentration. On mental status examination, the Veteran was cleanly dressed and appeared visibly nervous, bouncing his legs when seen in the waiting area. His attitude was appropriate and forthcoming, with good eye contact. He became tearful when he described worsening of anxiety symptoms, loss of jobs, and not being able to provide for his daughters. He continued to bounce his legs in nervousness and had mild bilateral hand tremor during the entire interview. It was noted that the Veteran's mood was bad and his affect was full, appropriate, and engaging. His speech was rapid, but regular in rhythm, volume, and tone. His thought process was linear, logical, and goal-directed, and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight and judgment were fair, with adequate fund of knowledge. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems adjusting to work and stressors of everyday life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder versus panic attacks; mood disorder, not otherwise specified; rule out bipolar disorder; and posttraumatic stress disorder (PTSD) on Axis I. The VA psychiatry resident noted poor coping mechanisms on Axis IV, and listed a GAF score of 55 to 60. An addendum by a VA psychiatrist stated that the Veteran presented with a history of and objective signs of considerable anxiety. It was noted that no psychotic indicators or evidence of a major affective disorder was shown. It was also noted that the Veteran's functioning had been impaired for some time and he was heavily using marijuana but denied using other substances. A November 2008 VA psychiatry report stated that the Veteran was visibly more anxious and related that his girlfriend left him and his family was helping with his son. The Veteran was more anxious and worried about generalized things, and reported continued use of marijuana to help with anxiety. He reported that he started going church again. He denied any suicidal or homicidal ideations, auditory or visual hallucinations, or psychotic indicators. On mental examination, the Veteran was casually and cleanly dressed and appeared nervous, sitting bouncing his legs. He was cooperative and forthcoming during the interview and showed positive mental attitude. He continued to have nervous mannerisms. It was noted that his mood was depressed and angry; his affect was congruent with mood and appropriately tearful at times; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was poor and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems adjusting to work and stressors of everyday life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted poor coping mechanisms on Axis IV, and listed a GAF score of 60. It was noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends, and did not present an acute risk of harm to self for others. The Veteran was afforded a VA mental examination in November 2008. The Veteran reported a history of suicide attempt by overdose in 2004 after taking several medications used to treat his psychiatric condition in service. He thought this suicidal attempt might be related to the antidepressant he took at that time for he did not experience any suicidal thought prior to taking the medication. The Veteran stated he had not sought any psychiatric treatment or taken any psychiatric medication until October 2008, when he had an outpatient psychiatric visit at a VA Medical Center and was started on Zoloft and clonazepam. The Veteran reported feeling anxious and depressed off and on and more so in the past week after his girlfriend left him. He reported flashbacks and nightmares related to his cousin's death and waking up in sweats. He had difficulty falling asleep every day, decreased energy level, reduced appetite, and diminished ability to concentrate. He denied feelings of worthlessness, suicidal thought, or wishes to die. He also denied any psychotic symptoms. On mental examination, the Veteran was casually and cleanly dressed, with cooperative attitude and good eye contact. He was alert and fully oriented. He had marked psychomotor agitation, shaking both legs constantly during the interview. His speech was clear with normal rate, amount, and volume. He described his mood as anxious and depressed. His affect was anxious, slightly-constricted, appropriate, and congruent with mood; and thought process was goal-directed and well-organized. No signs or complaints of delusions or hallucinations were shown. The Veteran denied suicidal or homicidal ideation. It was noted that he had limited insight but fair judgment. The diagnoses were anxiety disorder, not otherwise specified; rule out PTSD, chronic, secondary to childhood trauma; and cannabis dependence. A GAF score of 51 to 55 was listed. The examiner noted that the Veteran's anxiety symptoms would cause significant reduced productivity and marked interference in his ability to interact effectively and work efficiently. The examiner stated "[a]s a matter of practicality and not scientific certainty, 80% of his impairment in his general functioning may be attributed to anxiety disorder and 20% to cannabis dependence." It was also noted that the Veteran had the ability to manage his own personal and financial affairs. In a November 2008 VA psychiatry note, the Veteran reported that he had been actively looking for work and stopped marijuana use for 21 days now. He reported being very anxious because he was going to meet his ex-girlfriend and was afraid that she would take their son and run off with him. On mental examination, the Veteran was cleanly and appropriately dressed, appeared nervous objectively, and reported anxiety subjectively. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was depressed; his affect was full and appropriate; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems adjusting to work and stressors of everyday life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted poor coping mechanisms on Axis IV, and listed a GAF score of 60. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a December 2008 VA psychiatry report, the Veteran reported difficulties with his past relationships. He also reported problems with his welfare case worker as she continued to call his ex-girlfriend the 'legal guardian' and this irritated him because he felt that he was the more responsible parent to their child. He related that he felt he had strong work ethic and tried to be the opposite of all of his three stepfathers. He stated that he did not want to be like his own family with broken relationships and multiple children with multiple women, however, he had done this and felt guilty about this. He denied suicidal or homicidal ideation, or auditory or visual hallucinations. On mental examination, the Veteran was cleanly and appropriately dressed. He still bounced his legs during the interview, less in the beginning and more as he talked more of his problems. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was depressed; his affect was full and appropriate; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems adjusting to work and stressors of everyday life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. A December 2008 VA psychiatry report reflects that the Veteran was seen and his son accompanied him because of babysitting problems. He was appropriate and interactive during the session, and did not display any concerning isolative behaviors or tearfulness, and his verbal content was future-oriented. On mental examination, the Veteran was cleanly dressed. He still bounced his legs during the session, less in the beginning and more as he talked more of his problems. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was depressed; his affect was full and appropriate; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems with anxiety interfering with everyday life. It was noted that the Veteran had poor insight into his poor decision making and its adverse effects on his life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a December 2008 VA psychiatry report, the Veteran stated that he had been given temporary custody of his son and he was trying to get back on welfare and get help to support his son. He stated that he was not interested in a relationship. He denied any suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. On mental examination, the Veteran was cleanly dressed and his son accompanied him. The Veteran still bounced his legs during the session, less in the beginning and more as he talked more of his problems. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was depressed; his affect was full and appropriate; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems with anxiety interfering with everyday life. It was noted that the Veteran had poor insight into his poor decision making and its adverse effects on his life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a January 2009 VA psychiatry report, the Veteran related that he understood that things might not work out with his ex-girlfriend, the mother of his son, and while he still loved her, she continued to degrade and hurt him. He reported multiple episodes of verbal and emotional abuse by her. The Veteran was still looking for work. On mental examination, the Veteran was cleanly dressed. He still bounced his legs during the session. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was depressed; his affect was full and appropriate; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems with anxiety interfering with everyday life. It was noted that the Veteran had poor insight into his poor decision making and its adverse effects on his life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 65 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a January 2009 VA psychiatry report, the Veteran reported feeling helpless as he was doing the right things, such as applying for jobs, applying for assistance to go to school, and taking care of his son, but things never seemed to work out for him. He was anxious and tearful when relaying his ex-girlfriend leaving him and his son the previous night. He denied suicidal ideation, and reported that he was the sole provider for his son. It was noted that the Veteran was strongly encouraged to not relay his current problems at the job interviews as he coped with his problems by telling everyone he came into contact with for advice. On mental examination, the Veteran was cleanly dressed. He still bounced his legs during the session. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was depressed; his affect was full and appropriately tearful when discussing girlfriend leaving him; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems with anxiety interfering with everyday life. It was noted that the Veteran had poor insight into his poor decision making and its adverse effects on his life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 65 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a February 2009 VA psychiatry report, the Veteran reported being happy that he found a job and started working. He related that his neighbors helped out with watching his son during the time he worked. On mental examination, the Veteran was cleanly dressed. He still bounced his legs during the session. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was "depressed"; his affect was full and appropriate to the content; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms, with visible anxiousness. The Veteran related that he was having problems with anxiety interfering with everyday life. It was noted that the Veteran had poor insight into his poor decision making and its adverse effects on his life. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 65 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a February 2009 VA psychiatry report, the Veteran reported that he had been working full time, but was unable to spend time with his son. He was also working with VA to get his bills paid and was planning to look into school. He stated that as things were going well, he felt that something bad was about to happen. He continued to abstain from marijuana and was able to work and function. On mental examination, the Veteran was cleanly dressed. He still bounced his legs during the session. He was cooperative and forthcoming during the interview, and showed positive mental attitude. The Veteran continued to have nervous mannerisms. It was noted that his mood was depressed; his affect was full and appropriate to the content; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 65 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. A March 2009 VA psychiatry report noted that the Veteran was calm playing with his son, with no complaints at the start of the session. He reported that he switched jobs to spend more time with his son. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He still bounced his legs but at times was resting without any bouncing. It was noted that his mood was "okay and overwhelmed"; his affect was full and appropriate to the content; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 65 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a March 2009 VA psychiatry report, the Veteran reported that he was getting by and feeling overwhelmed at times. He was trying to work as many hours as possible, spend time with his son, and get his bills paid. He reported continued guilt over not being able to pay child support for his daughters. He reported doing well at work and winning an award for having the most sales. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He still bounced his legs but at times was resting without any bouncing. It was noted that his mood was "okay and overwhelmed"; his affect was full and appropriate to the content; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 65 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. A March 2009 VA psychiatry report noted that the Veteran was very apologetic for being late for the appointment. He reported that he continued to maintain sobriety and work, and was now back with his ex-girlfriend. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He still bounced his legs but at times was resting without any bouncing. It was noted that his mood was "okay and overwhelmed"; his affect was full and appropriate to the content; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality disorder on Axis II and poor coping mechanisms on Axis IV. A GAF score of 65 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In a March 2009 VA psychiatry report, the Veteran reported that his girlfriend left again. He appeared calm and collected compared to the previous time when she had left him. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "not good"; his affect was full and appropriate to the content; speech was regular; thought process was linear, logical, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were anxiety disorder, not otherwise specified; rule out generalized anxiety disorder; mood disorder, not otherwise specified; rule out bipolar disorder; and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 55 to 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In an April 2009 VA psychiatry report, the Veteran reported being busy with his son, going to work, and keeping appointments. He talked about wanting to give his son the nuclear family he did not have, and that is why he continued to pursue reconciliation with his girlfriend. It was noted that he had limited friends and was on house arrest, but was very future-oriented, thinking about school and getting into another relationship. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "good"; his affect was full and appropriate to the content; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 55 to 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. An April 2009 VA psychiatry report noted that the Veteran was with his son again. He reported being anxious about the upcoming custody trial. He was still on house arrest. The Veteran reported continuing to work and working out at home to channel his energy. He related that he felt down because friends were not coming around despite his calling. He reported that he still spoke with his brother and went to church. He denied any suicidal ideation as his son and religion were his protective factors. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "okay"; his affect was full and appropriate; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 55 to 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and from his brother and sister-in-law, and did not present an acute risk of harm to self or others. In an April 2009 VA psychiatry report, the Veteran stated that he had declined a relationship with a co-worker. He did not want to jeopardize his job situation as he felt losing his job would not be good for his son. He stated he continued to be intimate with his girlfriend and still hoped they will reconcile. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "okay"; his affect was full and appropriate; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with breakup with his girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 55 to 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. In an April 2009 VA psychiatry report, the Veteran stated that he was back with his girlfriend again. He felt more anxious about departure of his current VA psychiatry resident and discussed meeting the new provider. He reported not using any medications or drugs to relieve anxiety and feeling that talk therapy helped. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "okay"; his affect was full, appropriate, and smiling; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with his ex-girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had social support from friends and from his brother and sister-in-law, and did not present an acute risk of harm to self or others. In a May 2009 VA psychiatry report, the Veteran reported being frustrated living with his girlfriend as she did not help out in the house. He reported trouble sleeping at night, having thoughts that ran through his head, and feeling more anxious at night. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "okay"; his affect was full, appropriate, and smiling; speech was regular; thought process was logical, sequential; and goal-directed, and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was limited and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had social support from friends and family, and did not present an acute risk of harm to self or others. In a May 2009 VA psychiatry report, the Veteran reported that he made the decision to kick his girlfriend out of home and that he felt used and abused. She hit him and police were called, but the Veteran refused to press charges. He stated he was said his therapist was leaving. The Veteran reported continuing to work and taking care of his son. House arrest was due to expire in June, and he reported he understood the need to stay away from marijuana. On mental examination, the Veteran was well dressed and kept good eye contact and appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "okay"; his affect was full, appropriate, and smiling; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was improving and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with his girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. It was also noted that he had social support from friends and family, and did not present an acute risk of harm to self or others. In a June 2009 VA psychiatry report, the Veteran reported that he had a panic attack at work while on the phone with a customer. He described shortness of breath, heart racing, and feeling flushed and tingling all over. He was unable to say what triggered the attack, but described being particularly stressed. He was frustrated and worried about the custody issue. His ex-girlfriend was again living with them as she was homeless and no one else would help her. However, he stated he was able to maintain boundaries, telling her not to be disrespectful of him and refusing to drive her to work (which would have jeopardized his house arrest agreement). The Veteran reported continuing to work and doing a balancing act with finances in trying to pay major things off first, yet deal with expenses associated with his son's care and potential car mechanical problems. The ex-girlfriend was not contributing, but was still contesting custody and threatening to leave the state and take the son with her. On mental examination, the Veteran was well dressed, with good grooming and hygiene. He kept good eye contact and exhibited appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "okay"; his affect was full, appropriate, and smiling; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was improving and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with his girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran adamantly denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. He was not using any alcohol and stopped using marijuana around November 2008. It was also noted that he had good social support from friends and family, and did not present an acute risk of harm to self or others. A June 2009 VA psychiatry report noted that the Veteran continued to work, care for his son, and worry about the outcome of the custody dispute. He reported that the ex-girlfriend had gotten a studio apartment and expressed hope to move to a better place and get an education. He expressed that he felt he had made one step forward but two steps backwards. The therapist observed that the Veteran's moving forward was a strength and that the Veteran showed resilience even when multiple negative things happened. On mental examination, the Veteran was well dressed, with good grooming and hygiene. He kept good eye contact and exhibited appropriate behaviors. He was anxious and bouncing his legs. It was noted that his mood was "okay"; his affect was full, appropriate, and smiling; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was improving and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with his girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. He is the primary provider for his son. He was not using any alcohol and stopped using marijuana around November 2008. It was also noted that he had social support from friends and family, and did not present an acute risk of harm to self or others. In a June 2009 VA psychiatry report, the Veteran reported continuing to work, pay child support, and care for his son when he had him. The Veteran reported his son's mother is now in a studio apartment but intermittently seeing the Veteran. She called him on father's day to wish him a happy Father's Day "asshole." The house arrest anklet was to come off the next day, and he reported starting school in August. On mental examination, the Veteran was well dressed, with good grooming and hygiene. He kept good eye contact and exhibited appropriate behaviors. He was anxious and bouncing his legs at baseline. It was noted that his mood was "okay"; his affect was full, appropriate, and smiling; speech was regular; thought process was logical, sequential, and goal-directed; and thought content was without suicidal or homicidal ideation, auditory or visual hallucinations, or psychotic indicators. His insight was improving and judgment was fair. The VA psychiatry resident noted an impression that the Veteran had severe anxiety symptoms and poor coping mechanisms to deal with his girlfriend and custody issues. The diagnoses were generalized anxiety disorder and PTSD on Axis I. The VA psychiatry resident noted rule out borderline personality traits versus histrionic traits on Axis II and poor coping mechanisms on Axis IV. A GAF score of 60 was listed. The VA psychiatry resident noted that the Veteran denied any suicidal ideation, plan, or intent, and that he was rational and future-oriented. He was not using any alcohol and stopped using marijuana around November 2008. It was also noted that he had social support from friends and family, and did not present an acute risk of harm to self or others. At his November 2009 hearing before the Board, the Veteran testified that he had carried many jobs and could not stay on a job for a lengthy period of time. He reported that his anxiety prevented him from meeting new people and concentrating at school. He also reported that he had panic attacks all the time, with his legs and hands shaking and difficulty breathing at times. In November 2009, the Veteran submitted lay testimony from his acquaintance stating that the Veteran is always antsy, jittery, and shaking his legs, and has hard time standing in one place. Lay statements also indicate that the Veteran's mind drifts when he is around more to 3 to 4 people, has hard time sleeping at night, has bad dreams, and has difficulty holding a pen. A February 2010 VA psychiatry report noted that the Veteran was seen to reestablish his outpatient psychiatric follow-up, which had lapsed since June 2009. The VA psychiatry resident noted severe anxiety symptoms, constantly shaking legs and with voice trembling throughout the interview. It was noted that the Veteran rambled and his thought process was very tangential. He reported a history of anxiety for 15 years, nightmares, difficulty sleeping, increased startle response, and flashbacks. It was noted that the Veteran had difficult relationships and had lost several jobs due to anxiety. He tried to control his symptoms by smoking marijuana and drinking, taking hot baths and exercise, and journaling. He complained of constant chronic feeling of emptiness, sadness, paralysis, and uncontrollable shaking, and used dramatic expressions for his experiences. He reported decreased sleep with early and middle insomnia and 3 to 4 hours of sleep at night. He described constant worry and rumination about the past, present, and future, constantly switching topics, mostly preoccupied with being a failure as a father. He felt hopeless but tried to be faithful and take care of his son. He denied suicidality. He stated that anxiety recently worsened by financial problems and relationship issues. He also stated that he wanted to go back to school to become a special education teacher, but could not really find the motivation. The Veteran reported depression, feeling sad and helpless, disturbed sleep, increased guilt over not providing for his two daughters, decreased appetite due to nervous stomach, decreased concentration with ruminating and racing thoughts, and feeling hypersexual. He denied auditory or visual hallucinations, delusions, or ideas of reference. He reported sleepwalking tendency, feeling tense all the time, nightmares, flashbacks, and avoidance of things that reminded him of time in Iraq, include avoiding the people from the Corps. On mental status examination, the Veteran was cleanly dressed and appeared very anxious, shaking his legs throughout the interview. His attitude was pleasant but slightly intrusive and intermittent. It was noted that his mood was "sad"; affect was very anxious, restricted in range, and intense; speech was rapid but regular in volume and tone; thought process was logical, goal-directed, and slightly tangential; thought content was without suicidal or homicidal ideation; cognition was grossly intact; and insight and judgment were fair, with adequate fund of knowledge. The diagnoses were generalized anxiety disorder and PTSD on Axis I. Poor coping mechanisms, childhood trauma, and social and financial stressor were noted on Axis IV. A GAF score of 55 to 60 was listed. As to risk assessment, the VA psychiatry resident noted that the Veteran had risk factors of being male, one prior suicide attempt, using substance, and suffering from severe anxiety. However, it was noted that he was free of any suicidal ideation, plan, or intent, and that he was rational and future-oriented. He stated that his son and religion were protective factors. The VA psychiatry resident noted that the Veteran's acute risk of harm to self or others was low; however, chronic risk was elevated given the risk factors mentioned above. A March 2010 VA psychiatry report noted that the Veteran was seen on follow-up with severe anxiety type symptoms. The Veteran was pleasant, visibly anxious, constantly shaking legs, and slightly intrusive. He reported not trying the medication as prescribed. The therapist noted that the Veteran appeared to be self-medicating with more dangerous and addicting substances than the medications prescribed, at which the Veteran got upset. He continued to feel overwhelmed and was ruminating constantly, but tried to identify his goals. He denied any suicidal or homicidal ideation, and felt safe, stable, and motivated to continue therapy and set goals for this recovery. On mental status examination, the Veteran was cleanly dressed and appeared very anxious, shaking his legs throughout the interview. His attitude was pleasant but slightly intrusive and intermittent. It was noted that his mood was "overwhelmed, " affect was very anxious, restricted in range, and intense, but reactive; his speech was rapid but regular in volume and tone; thought process was logical, goal-directed, and slightly tangential; thought content was without suicidal or homicidal ideation; cognition was grossly intact; and insight and judgment were fair, with adequate fund of knowledge. The diagnoses were generalized anxiety disorder and PTSD on Axis I. Poor coping mechanisms, childhood trauma, and social and financial stressor were on Axis IV. A GAF score of 55 to 60 was listed. It was noted that the Veteran was free of any suicidal ideation, plan, or intent, and that he was rational and future-oriented. He stated that his son and religion were protective factors. The VA psychiatry resident noted that the Veteran's acute risk of harm to self or others was low, but his chronic risk remained elevated. In April 2010, the Veteran was afforded another VA mental examination. The VA examiner noted that the Veteran's claims file was reviewed. The Veteran was extremely anxious during the examination. He stuttered, had facial tic, perspired, and shook intermittently. His speech was rapid and pressured, and it appeared difficult for him to take in information. He appeared distracted and preoccupied. He reported recurrent nightmares of his cousin's death, and stated that loud noises he experienced in Iraq brought those past thoughts and feelings to the forefront of his thinking. The Veteran expressed his concerns related to his family and stated there was "always too much to concentrate on at one time." He reported panic attacks that occurred all day and every day, during which time he would experience racing heart, difficulty breathing, and a need to "get away." It was noted that the Veteran had significant stutter, which had been a problem, particularly in light of his work in telemarketing. His previous job history included seven jobs since his military service, most of them lasting only for a few months. He reported currently working as a telemarketer for six months. Before that he tried to go to school, and before that, he worked in telemarketing for three months. He was reported to make a meager wage, and subsists on VA benefits and help from a brother. The examiner noted since the prior evaluation, there were no reported or recorded changes in the overall symptom picture, adjustment capacity, vocational attitude, or other psychiatric markers of distress. As for relationships, he was not currently dating and continued to grieve the loss of his girlfriend and reported that he had limited social life. He reported seeing his two young daughters from his previous marriage, but less frequently than he would like. The examiner noted that the records revealed the Veteran had good social supports. It was noted that he appeared to have appropriate concern for his son and to have several meaningful relationships. On mental status examination, he was casually and cleanly dressed with good hygiene. He appeared extremely thin. His attention and concentration were impaired by a high level of distractibility, as well as what appeared to be overstimulation. The examiner commented on the Veteran's use of a high energy drink which the Veteran brought and drank during the examination. The Veteran reported that this behavior was highly unusual and that the only reason he used it was because he had not slept well the prior evening. He felt he needed it due to his fatigue. No delusion was shown. The Veteran was fully oriented, kept reasonably good eye contact, and denied current thoughts of suicidal or homicidal ideation. No perceptual aberrations or memory problems were shown. The Veteran's speech was pressured and rapid at times, but he denied symptoms of mania. He tapped his fingers on the table and became tearful when discussing the military. He exhibited a facial tic and there was a ruminative quality to the discussion about his cousin and his PTSD. Volume of speech, intonation, and interview behavior were within normal limits. The examiner noted that it was difficult to assess the Veteran's level of motivation for change, but there were no obvious signs or reports of pessimism or hopelessness. No history of gambling, stealing, eating disorder symptoms, or behaviors consistent with bipolar disorder were shown. The Veteran approached psychometric testing in an open and straightforward manner, and his results were considered representative of his current level of functioning. It was noted that while there was evidence of anxiety, the most significant elevations were on scales measuring depression and self-alienation. The Veteran also scored high on a subscale suggesting that he exhibited some of the personality characteristics associated with substance use disorders. The diagnoses were anxiety disorder, not otherwise specified; impulse disorder, not otherwise specified; alcohol abuse; and cannabis dependence on Axis I, and a GAF score of 51 to 55 was listed. The examiner noted that the Veteran experienced a myriad of anxiety and depressive symptoms evident in both the interview and in psychological testing. He also had longstanding problems of cannabis dependence and alcohol abuse. He had a variety of impulsive behaviors, to include hypersexuality, attraction to reckless behaviors, and substance abuse; and unusual compulsive symptoms. It was noted that the Veteran failed to meet all requisite criteria for a specific impulse control disorder or for generalized anxiety disorder, but his problems with impulse control were quite salient. The examiner concluded that the Veteran's psychiatric symptoms seemed best explained by the diagnoses of anxiety disorder and impulse control disorder rendered at the time of the examination. The examiner opined, relating to occupational functioning, that the Veteran's anxiety symptoms probably resulted in a number of deficiencies in the workplace and in relationships, which was consistent with the findings of the previous VA examiner. It was noted that the Veteran was currently seeking a new job but aside from his four years in service, his resume suggested vocational instability and poor judgment. The examiner opined that the Veteran's level of impairment would likely cause unreliability, distractibility, decreased productivity, coworker conflicts, and difficulty following directions. It was noted that the Veteran presented preoccupied and distant; but was capable for sedentary employment, managing his home, caring for his son, providing family structure, and managing personal hygiene and other daily activities. The examiner stated that at the current time, the Veteran was not engaged in psychotherapy and his compliance with prescribed medication was questionable. It was found that the Veteran was competent to manage benefits based on the information available at the time of the examination. Following the Memorandum Decision, the Veteran underwent a private psychological examination in December 2012. After describing the Veteran's military history, the psychologist described the significant impact the Veteran's anxiety has on his occupational functioning. The psychologist noted that the Veteran was fired from many jobs since his discharge from service due to his excessive anxiety-including his most recently reported job. He noted the job history as ranging from telemarketing to being in charge of marketing personnel, but the Veteran was unable to hold these employments because of his anxiety symptoms. The psychologist further indicated that the Veteran's anxiety symptoms were severe and warranted a diagnosis of generalized anxiety disorder that had evolved from anxiety disorder, not otherwise specified. During the timeframe on appeal, the evaluator noted that the Veteran's GAF scores have been between 51-65, and this was such "a significant range for one with such serious symptoms." The evaluator further noted the Veteran's determination of disability rose from 10 percent to 50 percent over the relevant timeframe and reflects increasing damage due to anxiety disorder, which went from moderate to severe. Further, he noted that the Veteran has not sought treatment for his anxiety disorder since 2010 and this is congruent with his anxiety disorder and avoiding his in-service experiences. He found that the continued evaluations have increased the Veteran's anxiety and depression, and caused him to experience low self-esteem. Following Minnesota Multiphasic Personality Inventory, the private psychologist indicated that his results reflect continued severe anxiety, feelings of worthlessness and helplessness, inadequacy, worry, and depression. His results are typical of people who try to self-medicate, as the Veteran has done, and he is unlikely to be frank and open in discussing his problems. In addition, persons with his results are characterized by self-devaluation, intropunitiveness, tension, and nervousness. In addition, persons with these results have depression, anxiety, guilt, rigidity of attitudes, feelings of inadequacy, sexual conflict, loss of work efficiency, initiative, and self confidence. They also tend to have insomnia, excessive/nonproductive rumination, and suicidal ideation or attempts. The private psychologist was troubled by the treatment records in which the Veteran's treating therapists stated that he had no suicidal ideation. He stated that because of the Veteran's history of a suicidal attempt with inpatient treatment for the same and, as a Marine, it is likely that the Veteran did not want to be placed on suicide watch by reporting suicidal ideations to treating professionals. In other words, the Veteran chose not to report suicidal ideations to treating professionals because he did not want to be put on suicide watch. The private psychologist found "significant suicidal ideation" based on there being no progression in reducing his anxiety and his feelings of hopelessness have increased. The Veteran does, however, state that his feelings of responsibility for his son help him fight those suicidal impulses. The psychologist opines that these conflicting feelings causes anxiety, interferes with his daily functioning, and "severely impair[s] his ability to maintain remunerative work activity." As a result, he becomes avoidant and passive. The Veteran reported adequate social relationships, but when he has called his friends for help in the midst of crisis and receives no response, it contributes to feelings of loneliness and worthlessness. The private psychologist listed the reasons for why the Veteran's GAF scores should have been lower than listed by his treating therapists and VA examiners. Namely, he noted the Veteran's hints of suicidal ideation, his significant anxiety and its noticeable symptoms, lack of friendships, inability to sustain effort and productivity in his work efforts, and inability to sit still. The private psychologist diagnosed the Veteran as having generalized anxiety disorder, panic disorder with agoraphobia, and dysthymic disorder. He assigned a GAF of 45. Upon review of the Veteran's claims file and interview of the Veteran, the private psychologist opined that its more likely than not that the Veteran is unable to obtain or maintain substantially gainful employment. In so opining, the psychologist pointed to his findings during the evaluation, and notes that the Veteran's generalized anxiety disorder contributes to his depressive disorder, which is magnified in its intensity and focus by his anxiety. Additionally, his anxiety disorder is directly related to his development of avoidance and other anticipatory anxiety reactions too many normal situations people face in life. The psychologist described the Veteran as being severely disabled in daily functioning, ability to maintain concentration/focus, and ability to maintain remunerative activity for any significant period of time. He further found that the Veteran has been unable to maintain occupational productivity since 2008 as evidenced by him being fired/released due to unreliability, distractibility, decreased productivity, coworker conflicts, and difficulty following instructions. The psychologist further indicated that although the Veteran has a strong desire to achieve, his service-connected anxiety disorder has impaired him to the extent the he is unable to obtain or maintain substantially gainful employment. After reviewing the evidence of record, the Board concludes that the Veteran's generalized anxiety disorder is most appropriately rated as 70 percent disabling for the entire timeframe on appeal, but no more. In making this determination, the Board finds that the severity of the Veteran's anxiety disorder symptoms goes beyond the symptoms required for a 50 percent disability rating. Moreover, the Board finds that the medical evidence of record does not support an evaluation in excess of 70 percent. The Veteran's recorded GAF scores during the pendency of this appeal have ranged from 45 to 65, with a majority of GAF ratings being 55 to 60. As noted above, a GAF score of 51 to 60 indicates moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational or school functioning (e.g., having few friends or having conflicts with peers or co-workers). 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 to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). During the pendency of this appeal, the Veteran's psychiatric symptoms have been manifested by severe anxiety; depression; nervous mannerisms, such as bouncing legs, shaking hands, significant stutter, and facial tic; constant panic attacks; impaired concentration with ruminating and racing thoughts; problems with impulse control; disturbed sleep; nightmares; flashbacks; increased startle response; avoidance behaviors; social alienation; decreased appetite due to nervous stomach; and hypersexuality. Furthermore, the evidence of record clearly shows significant difficulty establishing and maintaining effective work and social relationships. VA psychiatry treatments records indicate severe anxiety symptoms, with visible anxiousness, and problems adjusting to work and every life stressors. Notably, both the November 2008 and April 2010 VA examiners found that the Veteran's anxiety symptoms would cause significant reduced productivity and marked interference in his ability to interact effectively and work efficiently. The April 2010 VA examiner's opinion suggests that the Veteran's level of impairment would likely cause unreliability, distractibility, decreased productivity, coworker conflicts, and difficulty following directions. Finally, the December 2012 private psychologist indicated that the symptoms of anxiety and depression cause the Veteran to be unable to obtain or maintain any substantially gainful employment. This is evidenced by his spotty employment history since service separation and the increasing severity of his anxiety symptoms. The Veteran reported to the December 2012 evaluator that he had to quit his most recent job due to his anxiety symptoms. In considering this disability as a whole, the Board concludes that the Veteran's generalized anxiety disorder is most analogous to the symptoms warranting a 70 percent rating for generalized anxiety disorder. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Accordingly, a disability rating of 70 percent is warranted for service connected generalized anxiety disorder for the entire timeframe on appeal. The evidence does not reflect that the Veteran's generalized anxiety disorder has been manifested by symptoms of such severity to warrant a higher disability rating in excess of 70 percent, at any time during the pendency of this appeal. Objectively, the Veteran has been cleanly and appropriately dressed, fully oriented, cooperative, rational, and kept good eye contact. He has exhibited a generally depressed mood; significant symptoms of anxiety and panic attacks; appropriate to slightly constricted affect; regular to tangential speech; logical and goal-oriented thought process; thought content without homicidal ideations, auditory or visual hallucinations, delusions, or psychotic indicators; adequate fund of knowledge; poor and limited insight; and poor to fair judgment. The evidence does not show this condition to be manifested by symptoms such as grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place, or memory loss. In addition, there are no obsessional rituals which interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant; spatial disorientation, and neglect of personal appearance and hygiene. In other words, the Veteran's symptoms are most analogous to those related to occupational and social impairment with deficiencies in most areas than related to total occupational and social impairment. And although the Veteran clearly has a serious disability, he exhibits few of the symptoms noted as applicable for a 100 percent rating. Moreover, inability to establish and maintain effective relationships is not shown. The evidence shows that the Veteran has significant difficulty maintaining a job for a lengthy period of time and his occupation history suggests vocational instability. The record reflects that he was able to maintain various employments whenever available and continued to work since February 2009. The most recent evaluation reflects that the Veteran is unable to obtain or maintain any substantially gainful employment due to anxiety disorder based upon his spotty post-service work history and the reasons for job termination. As for his social impairment, the record reflects that the Veteran has several meaningful relationships in life. Although he reported limited social life and difficulty in relationships, he maintains close relationships with his family, has appropriate concern for his son as the primary provider of his son, and has some contact with his daughters from his previous marriage. The record also reveals that he had a history of good relationships with friends, but that has deteriorated over the years. The Veteran clearly exhibits social impairment, and this is contemplated in the currently assigned 70 percent disability rating, which accounts for difficulty in establishing and maintaining effective work and social relationships. The next highest rating, a 100 percent rating, refers to a total inability to establish and maintain effective relationships. The evidence of record does not reflect this level of social impairment. As noted above, the Veteran was generally able to get along well with his close family and neighbors. The record reflects that he had been caring for his son, and his brother provided financial assistance to the Veteran. The record also indicates that he goes to church and he stated his son and religion were the protective factors in his life from suicidal ideation. Accordingly, the Board concludes that a 70 percent disability rating, but no more, is warranted in this case. See 38 C.F.R. § 4.130, Diagnostic Code 9400. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service connected generalized anxiety disorder, the evidence shows no distinct periods of time during the pendency of this appeal, during which the Veteran's generalized anxiety disorder has varied to such an extent that a rating greater or less than 70 percent would be warranted. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Rating Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's disability picture was not as unusual or exceptional in nature as to render his 70 percent rating inadequate. The Veteran's generalized anxiety disorder is evaluated as a mental disorder pursuant to 38 C.F.R. § 4.130, the criteria of which is found by the Board to specifically contemplate the level of disability and symptomatology exhibited by the Veteran's generalized anxiety disorder. When comparing the disability picture of the Veteran's generalized anxiety disorder with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by a 70 percent disability rating for his service connected generalized anxiety disorder. This includes consideration of symptoms such as flattened affect, disturbances of motivation and mood and difficult establishing and maintaining effective work and social relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). A rating in excess thereof is provided for certain manifestations of the service-connected generalized anxiety disorder but the medical evidence of record did not demonstrate that such manifestations were present in this case. The evidence does not show this condition to be manifested by symptoms such as obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place, or memory loss; and neglect of personal appearance and hygiene. Id. The criteria for a 70 percent disability rating more than reasonably describes the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate and no referral is required. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim for an increased rating in excess of 70 percent for generalized anxiety disorder, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) ORDER Entitlement to a rating of 70 percent, and no greater, for anxiety disorder is granted, subject to the laws and regulations controlling the award of monetary benefits. REMAND The Board notes that a claim for a total disability rating based on unemployability (TDIU) may be presented informally or may be raised by the facts. "Once a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability, the 'identify the benefit sought' requirement of 38 C.F.R. § 3.155(a) is met and the VA must consider TDIU." Roberson v. Principi, 251 F. 3d 1378, 1384 (Fed. Cir. 2001). The evidence of record shows the Veteran's contentions that he believes he is unemployable due to his anxiety disorder. There is a notation in the December 2012 private evaluation indicating that the Veteran may be totally and permanently disabled. The Board finds that a claim for a TDIU has been raised by this case. The Board notes that according to the VA General Counsel, the question of TDIU entitlement may be considered as a component of an appealed increased rating claim if the TDIU claim is based solely upon the disability or disabilities which are the subject(s) of the increased rating claim(s). See VAOGCPREC 6-96. VA General Counsel opinions are binding on the Board. See 38 U.S.C.A. § 7104 (c) (West 2002); 38 C.F.R. § 14.507 (2012). Here, the Veteran has essentially claimed that the disability on appeal is the cause of his unemployability. Therefore, the Board finds that further action is required of the originating agency before the Board decides the TDIU issue. Accordingly, the case is REMANDED for the following action: 1. The RO should provide all required notice in response to the Veteran's most recent claim of entitlement to a TDIU. 2. The RO should undertake appropriate development to obtain a copy of any outstanding records pertinent to the Veteran's claims. 3. Then, the RO also should arrange for the Veteran to be scheduled for a VA examination by an examiner with the sufficient expertise to ascertain the severity and manifestations of his service-connected anxiety disorder. The claims folders and any pertinent evidence in Virtual VA that is not contained in the claims folders must be made available to and reviewed by the examiner, and any indicated studies should be performed. The RO should ensure that the examiner provides all information required for rating purposes. The examiner should also provide an opinion concerning the impact of the Veteran's service-connected anxiety on his ability to work, to include whether it is sufficient by itself to render the Veteran unable to obtain or maintain any form of substantially gainful employment consistent with his education and employment background. The supporting rationale for all opinions expressed must be provided. 4. The RO should also undertake any other development it determines to be warranted. 5. Then, the RO should readjudicate the Veteran's claims-including his claim for a TDIU due to his anxiety disorder. If the benefits sought on appeal are not granted to the Veteran's satisfaction, a Supplemental Statement of the Case should be issued to the Veteran and his representative and they should be afforded the requisite opportunity to respond before the case is returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is otherwise notified but he has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ L. J. BAKKE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs