Citation Nr: 1315299 Decision Date: 05/09/13 Archive Date: 05/15/13 DOCKET NO. 09-37 336A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to an increased rating for anxiety disorder with posttraumatic stress disorder (PTSD) features, currently rated as 50 percent disabling. 2. Entitlement to an increased initial rating for diabetes mellitus type II, currently rated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to November 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island, which granted service connection for diabetes mellitus type II and assigned a 20 percent rating, effective November 20, 2008, and increased the disability rating for anxiety disorder with PTSD features, from 10 percent to 50 percent, effective November 20, 2008. The Board notes that a claim for total disability based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the issue of entitlement to a TDIU rating has been raised by the record. Specifically, the Veteran and his wife have reported that he is unable to work due to his psychiatric disorder. However, during the pendency of the appeal, the Veteran filed a claim for entitlement to TDIU in December 2009, and the RO denied the claim in a March 2010 rating decision. The Veteran did not appeal this decision, and therefore, the issue of entitlement to a TDIU is not before the Board at this time. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The Veteran's symptoms of anxiety disorder with PTSD features have resulted in occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities; near-continuous depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships, and Global Assessment of Functioning scores of 40, 45, 50, 51, 53, 54, 55, and 60. 2. The Veteran's diabetes mellitus has been manifested by the need for oral hypoglycemic agents, dietary restrictions, and clinical regulation of physical activity. He has not required the use of insulin, and he does not have any diabetic complications. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9413 (2012). 2. The criteria for an initial rating in excess of 20 percent for diabetes mellitus type II have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in a November 2008 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. Additionally, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for a higher rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter also advised the Veteran of the necessity of providing medical or lay evidence demonstrating the level of disability and the effect that the disability has on his employment. The notice also provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The November 2008 letter further advised the Veteran of how effective dates are assigned, and the type of evidence which impacts those determinations. Regarding the issue of an increased initial rating for diabetes mellitus type II, the appeal arises from the initial award of service connection. In Dingess, the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i) (2012). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA and private medical records, VA examination reports, Social Security Administration records, lay statements, and the Veteran's statements. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Anxiety Disorder with PTSD Features The Veteran contends that he is entitled to a higher disability rating for his anxiety disorder with PTSD features. Such disability has been rated under 38 C.F.R. § 4.130, Diagnostic Code 9413, as 50 percent disabling. Under Diagnostic Code 9413, which is governed by a General Rating Formula for Mental Disorders, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and/or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for 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/or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted 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 a work-like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 71 to 80 indicates 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). A GAF score of 61 to 70 indicates some mild symptomatology (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, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2012). On VA examination in December 2008, the Veteran described his relationship with his second wife as being "fine," but he later indicated that he had frequent arguments with his wife where they would end up not speaking to each other for days. He reported that his relationship with his daughter was characterized by increased frequency of arguing, but stated that he had good relationships with his son and grandchildren. He indicated that he did not see his siblings very often because he just stayed in the house most of the time. He explained that he does not have problems with people if they understand him. He maintained that he had one friend that he would talk to on the phone a couple of times a week. The Veteran reported that he was currently unemployed but that he had previously worked at a company where he ran the waste water treatment plant, and also as a truck driver. He maintained that he had not had any problems at work if he had been able to work alone. He stated that he left his job at the waste water treatment plant because he had to undergo back surgery for his arthritis of the spine. He also indicated that he could not currently work due to his physical problems. The Veteran also complained of daily intrusive recollections of traumatic military events, nightmares of traumatic events if he watched something upsetting on the television, avoiding Asian restaurants and people because he associated them with his traumatic military events, a loss of interest in significant activities, sense of a foreshortened future, sleep difficulty where he got only 3 to 4 hours of sleep a night, irritability and anger outbursts, hypervigilance, exaggerated startle response, periodic depressed mood, weight loss of 10 pounds over the past 3 to 4 months, psychomotor agitation, loss of energy and fatigue, and excessive feelings of guilt and self-blame or worthlessness. The Veteran endorsed some thoughts that life was not worth living as well as thoughts about hurting himself, but denied any suicidal plan or intent or past suicidal attempts. He also denied homicidal ideation, hypomania, or mania. He reported that he had a hobby of collecting coins. He maintained that he liked to go to the casino every two to three months but that when he arrived there, he would want to leave because there were too many people. He stated that in a typical day, he would take his grandchildren to school and then watch television. Examination revealed that the Veteran was casually and appropriately dressed, and hygiene was adequate. Posture, gait, gross and fine motor skills, and psychomotor activity were all within normal limits. Rate, volume, and articulation of speech were within normal limits, although his speech tended to be very soft and his responses very brief at the beginning of the examination. Affect was somewhat depressed, and mood was described as somewhat depressed and irritable. Affect was full range, content appropriate, and mood congruent. The Veteran was well-oriented with the exception of identifying the season as winter rather than fall. Abstract reasoning and memory for recent and remote events were intact, but there was slight impairment in immediate memory. Attention was not impaired during the interview portion of the examination, but there was slight impairment in attention during the mini mental status testing. Thought form was lucid and coherent, and the Veteran was not tangential or circumstantial. Thought content was appropriate and was not obsessional or delusional. Insight and judgment were both adequate. There was evidence of some PTSD symptoms, depressed mood, and anhedonia. However, there was no evidence of obsessions, compulsions, ideas of reference, hallucinations, delusions, specific fears, social fears, excessive worry, hypomania, mania, panic attacks, agoraphobia, impaired impulse control, or social isolation. Regarding concentration, the Veteran was able to state the days of the week backwards and was able to self-correct when he made a mistake in stating the months of the year backwards. He complained of not being able to sit through a movie and having difficulty completing tasks in his everyday household routine. The Veteran was diagnosed with anxiety disorder with PTSD features and depressive disorder. The examiner assigned a GAF score of 50 and explained that this score reflected a moderately severe degree of impairment in occupational, social, and interpersonal functioning. The Veteran's symptoms were found to have had a moderate effect on his ability to maintain and sustain gainful employment. The examiner noted that due to his irritability and anger, the Veteran was able to function in jobs where he could work in isolation away from other people. The examiner also noted that the Veteran had reported frequent arguments with his wife and daughter, which represented an increase in frequency since the last VA examination. At a January 2010 VA examination, the Veteran reported that his marriage was good, but admitted that he had a bad temper and that when he was angry with his wife, he would throw things and lay in bed for three or four days without speaking to her. He also stated that he tended to get into arguments with his daughter about how to raise her children. He indicated that he had good relationships with his eldest sister and brother, as well as with his son and daughter. He maintained that he had 3 friends, but that he tended to stay by himself even though one of his friends would call him every few days. He reported being casually acquainted with his neighbors and having no problems with authority figures. The Veteran also complained that he had problems with sleeping, anger, and irritability. He indicated that he had a short fuse and could not cope with road rage. He reported that in a typical day, he would have a light breakfast at home, go out for coffee later in the day, and look through his coin books and watch television at home. He stated that he sometimes took his wife out on errands, but that if she had to go into crowded places, he would stay in the car. He indicated that with regards to tasks, he was able to complete everyday household tasks, but tended to drag them out so that he would have something to do. Examination revealed that the Veteran was cooperative, pleasant, reliable in his self-report, and neatly dressed and groomed. Eye contact was good, and speech was within normal limits. The Veteran was not withdrawn or agitated. There was no evidence of motor retardation, motor abnormalities, auditory hallucinations, tactile hallucinations, visual hallucinations, altered level of consciousness, obsessive thinking, compulsive behaviors, or impaired ability for self-care. The Veteran could not recall six digits forward or five digits backwards, but could recall five digits forward. He could not name the United States presidents in reverse order beyond President Reagan with the exception of George Bush Sr. He was able to interpret all proverbs. Concentration was not impaired, and abstract thinking was intact. Mood was described as good, and affect was one of mild anxiety. The Veteran denied any suicidal or homicidal ideation, history of suicidal or assaultive behaviors, alcohol or drug use, feelings of inadequacy, worthlessness, hopelessness, mania, hypomania, or panic attacks. He reported sleeping 7 hours a night with his medication but stated that his sleep was much less and interrupted without the medication. He indicated a good level of energy but a decreased libido. He maintained that his interests included collecting coins, watching car shows, and collecting model die cast cars. He complained that he worried about everything, including his grandchildren, wife, and other random situations. The examiner diagnosed the Veteran with anxiety disorder with PTSD features and depressive disorder. He assigned a GAF score of 50 and reported that the Veteran's symptoms had increased in intensity since his last VA examination. The Veteran's depression was noted to be secondary to his anxiety and expected to exacerbate his anxiety. The examiner found that the Veteran's symptoms had a moderate negative impact on his ability to obtain and maintain physical or sedentary employment because his thought processes and communication skills were expected to cause a significant interference with his social functioning. On VA examination in September 2011, the Veteran reported receiving anti-anxiety medication to treat his psychiatric symptoms, but indicated that there had been no improvement in his symptoms. Examination revealed that the Veteran was clean and casually dressed with persistent mannerisms. He had a cooperative attitude but was irritable. He was oriented in all spheres. Mood was anxious, and affect was constricted. Attention was intact, and the Veteran interpreted proverbs appropriately. Speech, thought process, and thought content were unremarkable. The Veteran understood that he had a problem and understood the outcome of behavior. He had suffered from an erratic sleep pattern for the past 10 years and would occasionally get only 4 hours or no sleep a night due to his "mind racing." There was no evidence of delusions, hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal thoughts, episodes of violence, or problems with activities of daily living. Memory was normal, and impulse control was fair. The examiner noted the presence of suicidal thoughts. The Veteran was also noted to have retired in 2005 due to back problems. The examiner diagnosed the Veteran with anxiety disorder and depressive disorder and assigned a GAF score of 53. He found that the nature, frequency, and severity of the Veteran's psychiatric symptoms were at approximately the same level as they had been during the December 2008 VA examination. The examiner determined that the Veteran's overall mental health functioning fell in the range of moderate symptomatology. He also found that due to his disability, the Veteran did not have total occupational and social impairment, nor did the Veteran have deficiencies in judgment, thinking, family relations, work, mood, or school. The examiner did determine that the Veteran had reduced reliability and productivity due to his psychiatric symptoms. He explained that the Veteran's distrust, irritability, and anger control problems interfered with his ability to successfully work with others, so this had led to him seeking solitary positions until he was forced to retire for medical reasons. VA medical records dated from January 2008 to July 2011 show that the Veteran received intermittent treatment for PTSD, depression, and bipolar disorder. He suffered from such symptoms as increased nightmares; flashbacks; irritability; depression; suicidal ideation where he has to avoid the porch to keep from jumping off of it; avoidance of war movies, Asian restaurants, crowds, and the news; hypervigilance; exaggerated startle response; outbursts of anger; anxiety; intrusive thoughts; racing thoughts; paranoia; auditory hallucinations of bells, his wife's voice, and voices telling him to jump off the porch; insomnia; difficulty concentrating; social isolation; anhedonia; difficulty experiencing loving emotions; and detachment and estrangement from others. The evidence indicates that the Veteran regularly received VA instruction on suicide prevention and safety planning. He also consistently reported getting into arguments and fights with his wife and daughter. Indeed, a July 2009 VA medical report reveals that the Veteran felt let down by his wife because she had not informed him that she was staying at a cabin for a wedding celebration as opposed to just spending time with her son. The Veteran complained of feeling upset and angry and having racing thoughts. He indicated that he had felt taken advantage of, lonely, and let down, and had consequently forbade his wife from ever traveling again. He stated that he and his wife were currently not talking to each other. Additionally, in a December 2010 VA treatment report, the Veteran indicated that his daughter had not spoken to him in 2 months. A May 2011 VA treatment report showed that the Veteran would only speak to 2 people. His daughter had informed him that eventually, he would have no one, and the Veteran had stated that he did not care. The Veteran's wife submitted statements dated in December 2008 and October 2009 in support of the Veteran's claim. The Veteran's wife reported that the Veteran had become increasingly irritable and did not sleep through the night. She stated that he would constantly yell at other cars when driving and that he frequently fought with his daughter. She indicated that she had witnessed the Veteran locking and unlocking the front door 10 times in a row. She maintained that the Veteran refused to attend family social functions such as dinners, weddings, funerals, and parties. She stated that the Veteran had refused to attend his stepson's wedding and had blamed her for staying away for so long instead of staying at home with him. The Veteran's wife also reported that when the Veteran became upset with her, he would argue with her for 3 hours and then storm off and stay in bed for 2 days. The evidence reveals that during the appeal period, the Veteran was assigned GAF scores ranging from 40 to 60. Specifically, the Veteran was assigned a GAF score of 60 in September 2009; a GAF score of 55 in January 2008 and April 2009; a GAF score of 54 in July 2011; a GAF score of 53 in July 2009, December 2010, May 2011, and September 2011; a GAF score of 51 in July 2008, April 2009, and May 2009; a GAF score of 50 in December 2008, May 2009, June 2009, December 2009, January 2010, and June 2010; a GAF score of 45 in November 2008; and a GAF score of 40 in March 2009. A GAF score of 40 is indicative of some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. GAF scores of 45 and 50 are indicative of serious symptoms or serious impairment in social, occupational, or school functioning. GAF scores of 51, 53, 54, and 55 are indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 60 is indicative of mild symptomatology or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, and resolving all reasonable doubt in favor of the Veteran, the Board finds that for all periods under consideration, the Veteran's PTSD is appropriately evaluated as 70 percent disabling. The Board acknowledges that on several occasions, the Veteran was assigned GAF scores of 51, 53, 54, and 55, which are indicative of moderate symptoms or moderate impairment in social or occupational functioning. Additionally, on one occasion, the Veteran was assigned a GAF score of 60, which is indicative of only mild symptomatology or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. However, VA regulations do not dictate that disability percentages are assigned based solely on GAF scores, see 38 C.F.R. § 4.130, and in this case, the overall evidence shows that the Veteran is entitled to a higher 70 percent rating for all periods under consideration. As outlined above, although the Veteran had a few friends and reported having good relationships with his family, the evidence indicates that he had frequent arguments with his wife and daughter. He admitted that he had a bad temper and that when he became angry with his wife, he would throw things and lay in bed for three or four days without speaking to her. The evidence also shows that on at least one occasion in December 2010, the Veteran's daughter had not spoken to him in 2 months due to an argument. The Veteran also reported in May 2011 that he would only speak to 2 people and that he did not care if he was eventually left with no one. Moreover, the Veteran did not see his siblings or friends because he preferred not to leave the house, and he even refused to attend family functions such as dinners, weddings, or funerals. The Veteran also suffered from severe, near-continuous depression that affected his ability to function independently, appropriately and effectively, as he refused to leave the house even for family functions. Indeed, the Veteran was unable to function independently and effectively when his wife left for a few days to attend her son's wedding in July 2009. He blamed her for leaving him and complained that he had felt taken advantage of, lonely, and let down. He had consequently forbade his wife from ever traveling again. Additionally, the evidence reveals that the Veteran experienced constant suicidal ideation, as he regularly received suicide prevention counseling and safety planning at his VA treatment sessions. Indeed, VA medical records indicate that the Veteran had to actively avoid his porch because he was tempted to jump off of it and would hear voices telling him to do so. Furthermore, the Veteran had difficulty in adapting to stressful circumstances, as he avoided crowded places when he took his wife on errands or when he went to a casino. He also coped poorly when his wife left him for a few days to attend her son's wedding and forbade her from ever traveling again because he thought that she should have stayed home with him instead. Moreover, in addition to experiencing continued sleep impairment, nightmares and flashbacks, social isolation, depression, exaggerated startle response, and anxiety, the Veteran exhibited intrusive and racing thoughts, hypervigilance, frequent auditory hallucinations, irritability, and outbursts of anger. The Veteran frequently heard bells, his wife's voice when she was not actually speaking, and voices telling him to jump off the porch. The Veteran was also hypervigilant to the point where he had obsessional rituals interfering with normal activities. His wife reported in December 2008 that she had frequently witnessed the Veteran locking and unlocking the door 10 times in a row. Additionally, although no impaired impulse control was found on VA examination in December 2008 or in September 2011, the evidence shows that the Veteran had frequent unprovoked episodes of irritability due to his anger control issues. Specifically, he often had arguments with his wife and daughter, and had many reported episodes of road rage. He also reported not being able to work unless he worked alone because he had anger control issues around other people. The Board acknowledges that the December 2008 VA examiner determined that the Veteran's anxiety disorder with PTSD features was only productive of moderately severe degree of impairment in occupational, social, and interpersonal functioning. The Veteran's symptoms were found to have had a moderate effect on his ability to maintain and sustain gainful employment. Similarly, the January 2010 VA examiner found that the Veteran's symptoms had only a moderate negative impact on his ability to obtain and maintain physical or sedentary employment because his thought processes and communication skills were expected to cause a significant interference with his social functioning. Finally, the September 2011 VA examiner determined that the Veteran's overall mental health functioning fell in the range of moderate symptomatology. He also found that the Veteran did not have total occupational and social impairment or deficiencies in judgment, thinking, family relations, work, mood, or school. The examiner instead determined that the Veteran had reduced reliability and productivity due to his psychiatric symptoms. However, despite the VA examiners' determinations, the Board finds that the overall symptomatology more nearly approximates the criteria for a higher rating. The Veteran's distrust, irritability, and anger control problems have interfered with his ability to successfully work with others, forcing him to work in isolation away from other people until retirement. The Veteran's anger control problems and tendency towards social isolation have caused him to be unable to maintain effective social relationships. The Veteran's constant moods of depression and irritability have impacted his judgment and thinking, causing him to have frequent suicidal ideation and feeling let down and taken advantage of if his wife left for a few days for travel. Thus, the Board finds that the Veteran's PTSD is productive of severe occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. See Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013). However, the evidence does not show that the Veteran's PTSD is productive of total occupational and social impairment. While the Veteran may have experienced persistent auditory hallucinations and has to constantly and actively prevent any suicide attempts, he does not have gross impairment in thought processes or communication, grossly inappropriate behavior, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Therefore, resolving all reasonable doubt in favor of the Veteran, an increased 70 percent rating is warranted for all periods under consideration. Diabetes Mellitus Type II Service connection for diabetes mellitus type II was granted by the February 2009 rating decision, with a 20 percent rating assigned under 38 C.F.R. § 4.119, Diagnostic Code 7913, effective November 20, 2008. Under Diagnostic Code 7913, a 10 percent rating is warranted for diabetes mellitus that is manageable by restricted diet only. A 20 percent rating is warranted for diabetes mellitus requiring insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Compensable complications of diabetes mellitus are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation under Diagnostic Code 7913. Noncompensable complications are deemed to be part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). On VA examination in December 2008, the Veteran was noted to have been diagnosed with diabetes mellitus type II in May 2008. The Veteran reported taking daily oral medication that he was tolerating without side effects. He denied any episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization in the past year or any visits to a diabetic care provider due to ketoacidosis or hypoglycemic reactions. He also denied any effects of diabetes on his occupational functioning or daily activities. He indicated that he had not been hospitalized for his diabetes. He maintained that he followed a diabetic diet and that he had lost at least 10 pounds in the past few months. The Veteran denied any specific restrictions in his activities related to diabetes. The examiner noted that an August 2008 diabetic retinopathy surveillance had shown abnormal results, but no specifics had been given. The Veteran stated that he had been blind in his left eye for his entire life and denied any right eye symptoms. There was no evidence of vascular symptoms, strokes, transient ischemic attacks, peripheral vascular disease, hypertension, cardiac symptoms or disease, heart attack history, coronary artery disease, paresthesias, or history of bowel or bladder functional impairment. The examiner diagnosed the Veteran with diabetes mellitus type II on oral agents and found no objective evidence of diabetes-related microvascular, macrovascular, or non-vascular complications. At a July 2011 VA examination, the Veteran was noted to be on oral medication for his diabetes mellitus. He was instructed to follow a restricted or special diet. He had also experienced episodes of hypoglycemia reactions that required hospitalization more than twice a year. These episodes required visits to a diabetic care provider every month or less often. As a result of the episodes of hypoglycemia, the Veteran was restricted in his ability to perform strenuous activities. Specifically, he was instructed to avoid fishing or clamming in order to prevent hypoglycemic episodes. The Veteran was noted to have a positive history of hypertension and wheezing, productive cough. He reported having 20/200 visual acuity in the left eye that was congenital. Examination revealed that the Veteran had a history of congenital defect in the left eye. There was also evidence of intermittent numbness in the right anterior shin. The examiner confirmed that the Veteran had a diagnosis of diabetes mellitus type II and found that it had moderate effects on his occupational functioning and mild to moderate effects on his daily activities. He noted that the Veteran had retired in 1996 due to left eye blindness and a back condition. Regarding potential diabetic complications, the examiner found that the Veteran's left eye impairment was not a diabetic complication because it was a congenital disability. The left eye condition was not worsened or increased by the diabetes. The Veteran's neuropathy in the right anterior shin was also not found to be a diabetic complication because it was attributed to low back degenerative joint disease status post surgery. It was not worsened or increased by the diabetes. Finally, the Veteran's hypertension was not considered to be a diabetic complication because it had preceded the diagnosis of diabetes mellitus by 5 years, and there was no renal impairment when the diabetes was diagnosed. The hypertension was also not found to be worsened or increased by the diabetes. VA and private medical records dated from January 2008 to July 2011 show that the Veteran received intermittent treatment for his diabetes mellitus type II. The evidence indicates that the Veteran followed a restricted diet, took oral medication, and was instructed to exercise. An August 2008 VA medical report indicated that the Veteran had no diabetic retinopathy or any other diabetes mellitus ocular risk factors. His diabetic foot examination was also normal. Subsequently in August 2008, a VA diabetic retinopathy surveillance/consultation revealed that the diabetic teleretinal imaging consultation was abnormal and referred the Veteran to optometry for follow-up in 2 to 3 months. At the December 2008 VA optometry follow-up consultation, the Veteran had no visual or ocular complaints. Upon visual, slit-lamp, and fundiscopic examination, the Veteran was diagnosed with type II diabetes of less than a year with no detectable retinopathy in both eyes. He also received diagnoses of refractive error with presbyopia and refractive amblyopia in the left eye with visual acuity of 20/400, longstanding and stable since childhood. The evidence consistently reflects that the Veteran has been following a restricted diet for his diabetes mellitus. It was noted at both of his VA examinations in December 2008 and July 2011. Indeed, the Veteran even reported at his December 2008 VA examination that he had lost at least 10 pounds in the past few months due to his diabetic diet. VA medical records consistently reflect that the Veteran had been instructed to exercise. However, at the most recent VA examination in July 2011, there was evidence that the Veteran had been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining regulation of activities, as used by VA in Diagnostic Code 7913). Indeed, he was advised to avoid fishing and clamming in order to prevent hypoglycemic episodes. Additionally, on VA examination in July 2011, the examiner found that the Veteran had experienced episodes of hypoglycemia reactions that required hospitalization more than twice a year. These episodes required visits to a diabetic care provider every month or less often. However, despite the recent worsening of the Veteran's diabetes mellitus condition, the Veteran has not been prescribed insulin for his diabetes mellitus. The evidence still indicates that the Veteran has only been taking oral hypoglycemic agents to control his diabetes mellitus. Indeed, at the most recent VA examination in July 2011, the examiner noted that the Veteran was on oral medication only for his diabetes mellitus and that he took this medication twice a day. The criteria under Diagnostic Code 7913 are conjunctive, not disjunctive; thus all criteria must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). In this case, although the Veteran may have been prescribed a restricted diet, advised to avoid strenuous activities, and hospitalized more than twice a year for hypoglycemic episodes, he does not require insulin treatment for these symptoms. Therefore, an initial rating in excess of 20 percent is not warranted for the Veteran's diabetes mellitus type II. Additionally, the Board has considered whether the Veteran has any diabetes-related complications that would warrant separate compensable ratings. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). In this case, neither the December 2008 or July 2011 VA examiner found any diabetes-related complications. Although an August 2008 diabetic teleretinal imaging consultation was abnormal, a subsequent optometry follow-up consultation in December 2008 revealed no detectable diabetic retinopathy in both eyes. Similarly, the July 2011 VA examiner determined that the Veteran's left eye impairment was not a diabetic complication because it was a congenital disability. Furthermore, the July 2011 VA examiner found that the Veteran's neuropathy in the right anterior shin was not a diabetic complication because it was attributed to low back degenerative joint disease status post surgery. He also determined that the Veteran's hypertension was not a diabetic complication because it had preceded the diagnosis of diabetes mellitus by 5 years, and there was no renal impairment when the diabetes was diagnosed. Finally, the July 2011 VA examiner concluded that the Veteran's left eye disability, neuropathy in the right anterior shin, and hypertension were not worsened or increased by the diabetes mellitus. Therefore, the Board concludes that the Veteran does not have any diabetes-related complications that would warrant separate compensable ratings. Other Considerations The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of his anxiety disorder with PTSD features and diabetes mellitus type II. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluations assigned and do not more nearly approximate the criteria for higher evaluations at any time during all relevant periods on appeal. See 38 C.F.R. §§ 4.119, Diagnostic Code 7913, 4.130, Diagnostic Code 9413 (2012); see also Fenderson, supra. The Board has also considered whether the Veteran's anxiety disorder with PTSD features and diabetes mellitus type II present exceptional or unusual disability pictures as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. With respect to anxiety disorder with PTSD features, the Veteran's 70 percent rating contemplates his functional impairment as well as his subjective complaints of depression, anxiety, suicidal ideation, irritability, and anger. The Veteran exhibited sleep impairment, nightmares, flashbacks, depression, intrusive and racing thoughts, frequent auditory hallucinations, exaggerated startle response, irritability, anxiety, hypervigilance with associated obsessive rituals, paranoia, exaggerated startle response, social isolation, and outbursts of anger. His disability was severe, but there was no evidence of total social and occupational impairment. Therefore, the Veteran's subjective complaints were included in the 70 percent rating. Regarding diabetes mellitus, the Veteran's 20 percent rating contemplates his subjective complaints as well as his functional impairment. Although the Veteran required restricted diet, regulation of activities, and hospitalization over 2 times a year for hypoglycemic episodes, these symptoms did not require insulin treatment. Additionally, the Veteran did not have any compensable diabetic complications that warranted separate ratings. Therefore, the Veteran's subjective complaints were included in the 20 percent rating. Thus, the Veteran's disability pictures are contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine in granting a 70 percent rating for PTSD. However, as the preponderance of the evidence is against the Veteran's claim for an increased initial rating for diabetes mellitus type II, that doctrine is not applicable to that issue. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER A 70 percent rating for anxiety disorder with PTSD features is granted, subject to the law and regulations governing the payment of monetary benefits. An initial rating in excess of 20 percent for diabetes mellitus type II is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs