Citation Nr: 1316907 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 10-27 438 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to an increased rating for a psychiatric disorder, currently evaluated as 30 percent disabling, to include the issue of a rating in excess of 10 percent, prior to November 30, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran had active service from April 1977 to April 1995. This matter came before the Board of Veterans' Appeals (Board) on appeal from an August 2008, rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), that denied the Veteran's claim for a rating higher than 10 percent for dysthymia. In a rating decision in April 2011, the RO increased the Veteran's disability rating for dysthymia to 30 percent effective November 30, 2010. However, as that grant does not represent a total grant of benefits sought on appeal, this claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified before the Board in November 2011. FINDINGS OF FACT For the entire appeal period, the Veteran's psychiatric disorder is shown to be productive of occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW For the entire appeal period, the criteria for a 50 percent rating, but not higher, for the Veteran's psychiatric disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.130, Diagnostic Code 9433 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in letters sent in May 2008, July 2008, and August 2009. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The letters provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disability under consideration, pursuant to the holding in Dingess v. Nicholson, 19 Vet App 473 (2006). The claim was readjudicated in the April 2011 supplemental statement of the case. The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim, and sought to have the Veteran described his symptoms. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records, Virtual VA file, and private and VA treatment records have been obtained. In addition, he has been provided with appropriate VA examinations in connection with the claim herein decided. He has not indicated there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claim, and no further assistance to develop evidence is required. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). By way of background, in a December 1995 decision the RO granted service connection for dysthymia. The RO assigned an initial evaluation of 10 percent. In May 2008, the Veteran submitted the current claim for an increased disability rating. In a rating decision in April 2011, the RO increased the Veteran's disability rating to 30 percent effective November 30, 2010. The Veteran seeks higher disability ratings. The Veteran's disability is rated under Diagnostic Code 9433 under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under such regulations, ratings are assigned according to the manifestation of particular symptoms. 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 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Under the General Rating Formula for Mental Disorders, the criteria for a 10 percent rating contemplate 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. The criteria for a 30 percent rating are occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The criteria for 50 percent rating are 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. The criteria for a 70 percent rating are occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. The criteria for a 100 percent rating are total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. Often, treatment records and examination reports contain a Global Assessment of Functioning score. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266 (1996); DSM-IV. GAF scores from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores from 51 to 60 indicate more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores from 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). GAF scores from 31 to 40 indicate some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family and was unable to work). GAF scores from 21 to 30 indicate that behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). 38 C.F.R. § 4.125; DSM-IV. Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for a higher disability rating have been met. It is the effect of the symptoms, rather that the presence of symptoms, that is the most important consideration. A VA clinical treatment note in August 2006, contained complaints of depression. Reportedly prescribed medication was not effectively treating his symptoms. Cognitively, the Veteran's speech was normal, eye contact and mood were good. Affect was not restricted, nonlabile and appropriate. There was no suicidal or homicidal ideation. The Veteran denied hallucinations or delusions. Thought process was logical and goal directed. Insight and judgment were good. Memory was grossly intact. The Veteran was assigned a Global assessment Functioning (GAF) score of 60. In July 2008, his GAF score was noted as 55. A January 2007 letter of reprimand from the Veteran's employer shows the Veteran was performing poorly at work and he had been unable to execute his duties as an accountant without supervisor intervention since approximately 2006. The employer noted that the Veteran's performance was indicative of a lack of comprehension of his position responsibilities. It was further noted that the Veteran had been performing roughly the same duties in similar position since July 1996 and his ability to perform these duties was not at issue. The employer indicated that if the cited deficiencies were repeated, progressive disciplinary action, up to and including termination, may be taken for any future violations. A performance evaluation noted that the Veteran did not meet standards required for his work position at several levels. A June 2008 private psychiatric evaluation report shows complaints of depression. The Veteran described his relationship with his mother as strained. The Veteran had been employed with the same employer for 12 years. He had been married once and described the relationship as normal. His hobbies included playing guitar, readings and computers. Dr. T.G., the Veteran's treating psychiatrist, described the Veteran as well groomed, casually dressed, soft spoken and polite. Mood and affect were mildly to moderately depressed and anxious. Thought processes were logical and goal oriented. The Veteran reported some paranoia pertaining to his work situation. He endorsed passing thoughts of suicide without plan. The Veteran was diagnosed with bipolar disorder and assigned a GAF score of 35. The Veteran underwent a VA examination in August 2008. The Veteran complained of depression, low energy, reduced sex drive, He described his symptoms as constant. He also related memory loss that reportedly had improved during the preceding months. Treatment consisted of medication and psychotherapy twice a months. There was no history of psychiatric hospitalizations. He denied panic attacks, hallucinations, delusions, obsessional rituals, suicidal or homicidal ideations. The Veteran was employed as an accountant for the prison system in Oklahoma for 10 years. He indicated that his job responsibilities had recently been significantly curtailed and he was in imminent danger of being fired. He characterized his relationship with coworkers and supervisors was good. The Veteran had no contact with his father and described a fair relationship with his mother. He had no siblings. The Veteran had been married once and had no children. He described the relationship with his wife as fair. Cognitively, orientation, memory, abstract thinking, judgment, thought processes, affect, mood, communication, speech, and concentration were normal and appropriate. His appearance, behavior and hygiene were appropriate. The examiner determined that an Axis I diagnosis was not appropriate indicating that there was a discrepancy between the Veteran's symptomatology and functional disability. The examiner diagnosed a GAF score of 79. The examiner determined that the Veteran had no difficulty performing activities of daily living. Psychiatric symptoms did not interfere with the Veteran's occupational and social functioning. He had no difficulty understanding commands. A VA treatment note in October 2008, shows that the Veteran reported down feelings but no suicidal thoughts. He denied suicidal or homicidal ideation. The Veteran also denied mania or hypomania. Thought process was goal directed. The Veteran was oriented times 3. He was appropriately dressed and groomed. He had good eye contact and speech was normal. His mood and affect were restricted. Insight and judgment were good. Memory was grossly intact. His GAF score was 55. A February 2009 clinical treatment report noted that the Veteran had a stable supportive family environment. In September 2009 the Veteran reported increased anxiety and anger. He denied any major mood symptoms or suicidal thoughts. There was no mania or hypomania. Thought process was goal directed. The Veteran was oriented times 3. He was appropriately dressed and groomed. He had good eye contact and speech was normal. His mood was anxious. Affect was normal in range. Insight and judgment were good. Memory was grossly intact. The Veteran reported having a stable supportive family environment. In a private medical statement in October 2009, Dr. T.G. described psychiatric symptoms that included depression, poor concentration and attention, memory problems, low energy and motivations, irritability, poor self esteem, preoccupation with death, anhedonia, and decreased appetite. The Veteran was diagnosed with bipolar disorder. Dr. T.G. noted that the Veteran's symptoms adversely affected the Veteran at work. Specifically, the Veteran had difficulty completing tasks and relating to other people on the job in a productive manner. In a November 2009 clinical treatment note Dr. T.G. described the Veteran's speech, behavior, affect, judgment, thought content, cognition and memory as normal. His mood was depressed. In a statement in October 2009, the Veteran complained of inability to perform work duties without supervision. He feared termination. He also reported marital problems. The Veteran reported not being truthful regarding suicidal/homicidal ideation on VA examination in August 2008. He also complained of memory problems and difficulty understanding directions from others due to racing thoughts. A VA treatment report in February 2010 recorded complaints of depression and worsening attention and memory problems. He reported difficulties at work. The Veteran indicated that he had 1 or 2 close friends and rarely participated in organized clubs or groups, but he expressed more difficulty than other people in making friends. He denied suicidal or homicidal ideation. There was no mania or hypomania. Thought process was goal directed. The Veteran was oriented times 3. He was appropriately dressed and groomed. He had good eye contact and speech was normal. His mood and affect were restricted. Insight and judgment were good. Memory was grossly intact. His GAF score was 55. On VA mental health disorders examination in November 2010, the Veteran complained of depression, being sad and tearful, low energy and motivation, irritability, impaired memory, diminished interest in recreational activates, poor concentration. He reported increased symptomatology in recent years. Treatment consisted of medication. He endorsed suicidal ideation with no plan or intent. The Veteran also related problems sleeping that he attributed to sleep apnea. The Veteran had been married for 22 years and had no children. He described spending most of the time at home in front of the TV or computer. He no longer engaged in social activities. The Veteran had a Bachelor's degree and many credits towards his Master's degree. While his last date of employment would be the day after the VA examination, he reported that in reality he had not actually worked since November 2010. His work performance had deteriorated in the previous years and he had spent the prior months sitting at his desk with no work to do. The Veteran stated that he decided to terminate his employment to avoid being fired, following numerous notifications from his employer regarding poor work performance. Reportedly, his work performance had been good until approximately 2006 when it started to decline due to mental health issue. He specifically attributed his decline in work performance to inability to focus, memory problems and low energy. On examination, the Veteran was described as casually and appropriately dressed. He was oriented to place, person and reason. His eye contact was mostly appropriate, although occasionally he looked down and away. Testing revealed good short term memory. There was no evidence of thought disorder, hallucinations or delusions. His appetite was variable. Cognitive functioning was characterized as fair. The Veteran was found to be capable of maintaining personal hygiene and carry out activities of daily living reasonably well. The examiner diagnosed dysthymic disorder and assigned a GAF score of 53. The examiner noted that the Veteran's psychiatric symptoms had increased in the previous 2 years have a significant impact on the Veteran's ability to stay focused and on task in his employment. The Veteran's work performance had been found to be seriously wanting by his employer who was ready to fire him. Additionally, in the last couple of years the Veteran's social activities had been significantly limited. The examiner opined that the Veteran's depressive disorder had developed to the point where it was significantly affecting his work capacities and social activities. Overall his psychiatric symptoms had become productive of considerable dysfunction. A VA clinical treatment note in January 2011 recorded complaints of anxiety, depression, labile moods, sleep disturbance and self isolation. He denied any major mood symptoms or suicidal thoughts. There was no mania or hypomania. Thought process was goal directed. The Veteran was oriented times 3. He was appropriately dressed and groomed. He had good eye contact and speech was normal. His mood was anxious. Affect was normal in range. Insight and judgment were good. Memory was grossly intact. His GAF score was 58. In March 2011, the Veteran complained of increased anxiety and memory problems. In April 2011 the Veteran reported worsening memory and concentration problems. The Veteran was concerned with the possibility that he may have dementia. He was frustrated about not working and being at home. He endorsed passive suicidal thoughts the previous week, but denied plan or intent. The clinician described the Veteran as appropriately dressed and groomed. He was oriented times 3. The Veteran exhibited good eye contact and his speech was normal. He was in good touch with reality. His mood and affect were restricted. Thought processes were goal oriented. The clinician noted limited insight and judgment, as well as impaired short term memory. The assessment was major depressive disorder, rule out dementia. At the personal hearing in November 2011, the Veteran and his spouse described memory problems and impaired concentration that interfered with the Veteran's ability to work and eventually resulted in disciplinary actions against him, and ultimately his voluntary termination. He also complained of sleep problems, self isolations, confusion and depression. The Veteran's spouse noted onset of symptoms in 2007-2008. He denied panic attacks. The Veteran's spouse described episodes of violence, to include an incident of apparent road rage that culminated with the Veteran pulling out a gun on the person with whom he had quarreled after the individual followed the Veteran home to continue arguing. The Veteran also yelled at another driver regarding parking. The medical evidence throughout the period on appeal contained complaints of irritability, difficulty sleeping, problems concentrating, depression, loss of interest in typically enjoyable activities, social isolation, suspiciousness, anxiety, low energy, reduced sex drive, difficulty communicating, racing thoughts, anger outbursts, confusion, low motivations, poor self esteem, difficulty completing tasks and relating to coworkers in a productive manner, preoccupation with death, anhedonia, and variable appetite. The Veteran's spouse noted onset of symptoms in 2007-2008, while his former employer reported problems at work since 2006. The Veteran consistently described his symptoms as constant and progressively worse. There were occasional reports of suicidal ideation without plan or intent. However, the Veteran consistently denied delusions and hallucinations, panic attacks, or obsessive ritualistic behaviors. While the Veteran's spouse described incidents of anger outbursts, to include an incident of apparent road rage that culminated with the Veteran pulling out a gun on the person with whom he had quarreled after the individual followed the Veteran home, this may not have been an unreasonable response in the context, and the Veteran consistently denied homicidal ideation. There was no history of psychiatric hospitalizations and the Veteran's treatment consisted of medication and outpatient treatment. While the treatment notes show that the Veteran's disability at times improved and worsened, thus requiring adjustment of medication, the Veteran generally reported that medications were effectively treating his symptoms. The medical evidence noted the following GAF scores; 60 in August 2006, 55 in July 2008, 35 in June 2008, 79 in August 2008, 55 in October 2008 and February 2010, and 58 in August 2010 and January 2011. Accordingly, the Veteran's GAF scores ranged from 35 and 79, with the majority of GAF scores being in the range of 51 to 60. After considering the evidence, the Board finds that for the entire period on appeal the Veteran's symptoms met the criteria for a 50 percent rating. He has described difficulty in making friends, and has become increasingly less interested in engaging in leisure or social activities. Occupationally, the evidence shows that as of 2006, the Veteran was experiencing increasing difficulties at work, which were attributed to his psychiatric symptoms. Specifically, the Veteran's increasing memory and concentration problems were interfering with his ability to complete work tasks. He was unable to perform work duties without supervision and complained of having difficulty relating to other people on the job in a productive manner. This is confirmed in a January 2007 letter of reprimand from the Veteran's employer. While the VA examiner in August 2008 determined that the Veteran had no difficulty performing activities of daily living and his psychiatric symptoms did not interfere with the Veteran's occupational and social functioning, the VA examiner in November 2010 opined that the Veteran's psychiatric symptoms had a significant impact on the Veteran's ability to stay focused and on task in his employment. This examiner noted that the Veteran's work performance had been found to be seriously wanting by his employer who was ready to fire him. Additionally, it was remarked that in the last couple of years the Veteran's social activities had been significantly limited. The examiner opined that the Veteran's depressive disorder had developed to the point where it was significantly affecting his work capacities and social activities. Records in 2009 revealed poor concentration and attention, and VA clinical treatment reports after 2011 showed limited insight and judgment, as well as impaired short term memory. In view of the foregoing, the Board concludes that with resolution of any reasonable doubt in favor of the Veteran, he has satisfied the criteria for a 50 percent evaluation during the appeal period. As to a rating in excess of 50 percent, with the exception of some suicidal ideation, the symptoms indicative of a 70 percent rating have not been shown by the evidence of record. There are no noted instances of such symptoms as obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships. Therefore, the Board does not consider the criteria for a 70 percent evaluation to be met. The Board has considered the statements and testimony of the Veteran regarding the severity of the service-connected psychiatric disorder, which was used in concluding an increased rating was warranted. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the rating criteria for the Veteran's service-connected psychiatric disorder reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptoms, which have not been shown. The medical evidence does not show that the Veteran's service connected disability causes unusual factors such as frequent hospitalizations or marked interference with employment beyond that contemplated by the rating schedule. The rating criteria are therefore adequate to evaluate the Veteran's psychiatric disorder and referral for consideration of extraschedular ratings is not warranted. With respect to whether the disability at issue renders the Veteran unemployable, the evidence does not show this. The rating itself acknowledges interference with working, which is a foundation of the rating schedule. Here, the Veteran voluntarily stopped working, and in any case, he was already been awarded a 100 percent scheduler rating by the combination of all his service connected disabilities, effective from 2010. ORDER Subject to the law and regulations governing the award of monetary benefits, entitlement to an increased rating of 50 percent for the Veteran's psychiatric disorder, is granted ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs