Citation Nr: 1318276 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 08-11 278 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California THE ISSUE Entitlement to a rating in excess of 50 percent for general anxiety disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from August 1963 until June 1964. This appeal to the Board of Veterans' Appeals (Board) arose from a June 2006 rating decision in which the RO awarded a 50 percent disability rating for generalized anxiety disorder, effective January 26, 2006. In February 2007, the Veteran filed a notice of disagreement (NOD). The RO issued a statement of the case (SOC) in February 2008, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in February 2008. The Board notes that, in August 2007, the RO also issued a rating decision denying an increased rating for general anxiety disorder. In the August 2007 rating decision, the RO indicated that the Veteran had filed a new claim for an increased rating in March 2007. However, as indicated above, in addition to the March 2007 statement wherein the Veteran requested a higher rating, the Veteran had also filed a NOD in February 2007. The VA received that NOD within a year of the June 2006 rating decision. As such, the Board is clarifying that the decision currently on appeal is the June 2006 rating decision. In March 2010, the Board remanded the claim on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for additional development. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. A review of the documents in such file reveals that some of the documents in the Virtual VA paperless claims file, i.e., VA treatment records dated from January 2012 to May 2011, are relevant to the issue on appeal and are not duplicative of the evidence in the paper claims file. However, such evidence was considered by the RO in its preparation of the February 2012 supplemental SOC (SSOC). FINDINGS OF FACT 1. All notification and development needed to fairly adjudicate the claim on appeal has been accomplished. 2. Pertinent to the January 2006 claim for increase and prior to September 21, 2010, the Veteran's general anxiety disorder was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. 3. Since September 1, 2010, the Veteran's depression has worsened and his general anxiety disorder now appears to be manifested by occupational and social impairment with deficiencies in most areas, due to symptoms such as obsessional rituals which interfere with routine activities, and near-continuous panic or depression. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for general anxiety disorder, for the period prior to September 21, 2010, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9400 (2012). 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for a 70percent, but no higher, rating for general anxiety disorder, from September 21, 2010, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321,4.3, 4.7, 4.130, Diagnostic Code 9400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations 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. 20112) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. A February 2006 pre-rating letter notified the Veteran as to what information and evidence was needed to satisfy the elements of a claim for increased rating, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. A separate March 2006 letter (located in the Virtual VA claims file) provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. It further specifically informed the Veteran to submit any evidence in his possession pertinent to the claim (consistent with Pelegrini and the version of 38 C.F.R. § 3.159 then in effect). There letters meet the Pelegrini and Dingess/Hartman content of notice requirements (as applicable), as well as the VCAA's timing of notice requirement. The June 2006 rating decision reflects the initial adjudication of the claim after issuance of the February and March 2006 letters. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of service, VA and private treatment records. Also of record and considered in connection with the appeal are various written statements provided by the Veteran, as well as by his representative on his behalf. The Board finds that no further RO action on this claim, prior to appellate consideration, is required. The Board notes that, in an October 2007 VA Form 21-4142, the Veteran reported that he had received private treatment from USC Family Medicine. Although the RO requested records from that facility in November 2007, those records were not received by the Board. The RO subsequently informed the Veteran in the February 2008 SOC that it had never received a response to that request. Although the RO never sent a follow up request to USC Family Medicine, the Board finds that the Veteran was not prejudiced by the RO's failure to do so, as the Veteran indicated that the treatment he received there was for his non-service-connected brain tumor and sufficient evidence was of record for the February 2012 VA medical opinion provider to form his opinion on whether the Veteran's dementia had begun in service. Additionally, consistent with the March 2010 Board remand, the AMC requested that the Veteran identify his private medical providers in a May 2010 letter. The Veteran did not provide the requested information. The AMC associated with the claims file VA medical records from the Social Security Administration (SSA) and arranged for the Veteran to undergo a VA examination in September 2010. The AMC also obtained an additional specialists opinion in February 2012. The Board notes that during his September 2010 VA examination, the Veteran's wife reported that he had received treatment for his anxiety disorder at Glendora Presbyterian hospital in the last two years. However, this treatment was not identified to VA following the May 2010 letter, wherein the AMC specifically requested that the Veteran identify his private medical providers. Additionally, during a December 2011 VA treatment, the Veteran, in the presence of his wife, reported that he had not seen a psychiatrist in years and was not interested in treatment from one. The Veteran also did not report such treatment to SSA in his August 2007 application. As the Veteran has not identified private treatment records for VA to obtain following VA's specific request for such information, the Board finds that the claim can be adjudicated without prejudice to the Veteran. A claimant cannot passively wait for assistance in circumstances where he should have information that is essential in obtaining the putative evidence. Wamhoff v. Brown, 8 Vet. App. 517 (1996); Wood v. Derwinski, 1 Vet. App. 190, reconsidered, 1 Vet. App. 406 (1991). The Board finds that no additional RO action in this regard is required. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate the claim decided herein, the avenues through which he might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Background Although only the rating assigned from January 26, 2006 is currently under consideration, for historical purposes, he Board will briefly review evidence relevant to the Veteran's disability prior to January 26, 2006. The Veteran served in the Navy from August 1963 until June 1964. A May 8, 1964 San Diego, California U.S. Naval Hospital record documents that the Veteran had been referred for nervousness prior to his ship's deployment. The Veteran reported that he had been nervous all his life, but that it had become worse since joining the Navy and reporting aboard his ship. Another May 8, 1964 record documented that the Veteran had always suffered anxiety, a diagnosis of emotional instability and a recommendation for administrative discharge. A July 1998 VA treatment record documents that the Veteran had mild anxiety, depression and memory problems. A January 23, 2006 VA treatment record notes that the Veteran presented with a somewhat dysphonic mood and flat affect. He reported a depression level of five out of ten. He denied suicidal ideation, though he had fleeting thoughts of suicide and of harming his wife in the past week. He reported good impulse control in that regard. He also reported feeling nervous over his financial circumstances. He denied auditory and visual hallucinations. Thoughts were linear, organized and appropriate to context. The examiner noted that speech was slightly slurred, due to poor dentition, but at a normal rate and prosody, and that the Veteran reported having difficulty setting limits. On VA examination in March 2006, the Veteran reported that he becomes nervous and things bother him, but that he was not excessively anxious at that time and did not worry about things. He felt restless and had poor concentration and irritability. He also reported decreased energy, psychomotor retardation and partial anhedonia. He denied suicidal ideation with plan, but had occasional homicidal thought. The examiner found the Veteran to have moderate anxiety and depression. The Veteran reported having numerous occupations after service and that he would walk off jobs when he no longer wanted to do them. The Veteran was working as a truck driver, with no supervisor, and reported getting along well with individuals. He further reported occasionally calling in sick due to not feeling emotionally well. The March 2006 VA examiner found the Veteran to be oriented to all spheres, casually dressed and cooperative, with fair hygiene and appropriate behavior, but slight psychomotor agitation. The Veteran reported an "okay" mood and the examiner noted a slightly depressed and anxious affect. The examiner noted normal speech, except for a slight lisp secondary to poor dentition. The Veteran also reported panic attacks a couple times a week, lasting 10 minutes. The Veteran reported no delusional ideation, but did note illusions on side of the road or corner of eyes, but no direct hallucinations. He also reported some obsessive rituals, such as checking his alarm time repeatedly. The March 2006 VA examiner found the Veteran's insight and judgment to be fair. The examiner also found an intact remote memory and mild difficulty with concentration. The Veteran reported suicidal ideation, without plan, and occasional homicidal ideation without plan or intent. The March 2006 VA examiner diagnosed the Veteran with general anxiety disorder, major depressive disorder and posttraumatic stress disorder, chronic (due to childhood molestation). The examiner assigned a GAF of 55, which was noted to indicate moderate symptoms (suicidal ideation, depression, panic attacks impairment in social functioning and occasional homicidal ideation). The March 2006 examiner found the Veteran mentally capable of managing benefit payments in his own best interests. The examiner noted moderate, ongoing difficulty in performing activities of daily living. There were difficulties stabling and maintaining effective work and social relationships, as well as socialization. However, the Veteran reported that those were diminishing over the course of his life. The Veteran had no difficulty understanding commands. In June 2007, the Veteran underwent another VA examination. The Veteran reported trouble sleeping, anxiety nervousness, restlessness and feeling uneasy, which he described as constant on almost a daily basis. The Veteran also reported difficulty socializing with people and not working since July 2006, though his relationship with supervisors and coworkers was fair. The June 2007 VA examiner found the Veteran to have normal orientation, appearance, hygiene, communication and speech and thought process, with appropriate behavior. Mood and affect were anxious, restless, fidgety and irritable. There were no panic attacks, delusions, hallucinations, ritualistic obsession. Thought processes were normal and judgment intact. Memory was mildly tom moderately abnormal, with difficulty with retention of highly learned materials and forgetting to complete tasks. He had no suicidal or homicidal ideations. The June 2007 VA examiner agreed with the prior diagnosis of general anxiety disorder, and assigned a GAF score of 55. The examiner found the Veteran mentally capable of managing his benefit payments in his own interest and to have occasional difficulty performing activities of daily living. The examiner further noted that the Veteran had problems establishing and maintaining work relationships and had problems with co-workers and supervisors; he had diminished social relationships. The Veteran had no difficulty understanding simple commands, but some difficulty with complex ones. An August 13, 2007 VA operative report documents that the Veteran's brain tumor was removed. An April 2, 2008 VA medical record includes notation that the Veteran had returned to work briefly in June 2007, but was permanently disabled after the August 2007 discovery of a brain tumor (glioblastoma multiforme). The Veteran reported doing things to pick on his wife, including banging his hand or arm against furniture. The Veteran denied suicidal or homicidal ideation, audio or visual hallucinations and anhedonia. The examiner found speech to be spontaneous, but terse, and that the Veteran was alert, with clear sensorium and anxious mood. The examiner noted relationship issues, generalized anxiety and possible obsessive traits. An April 16, 2008 VA medical record documents that the Veteran reported hitting and cutting himself to relax, especially when his wife would get upset and yell at him. A June 5, 2008 VA medical record notes that the Veteran had anxious mood and congruent affect, with pressured speech and no flight of ideas. The Veteran reported that he had many thoughts that bothered him, sometimes anxious, other times angry. The Veteran reported no suicidal or homicidal ideation, but that anxiety has been increasing. The Veteran had no audio or visual hallucinations or systematized delusions. An August 8, 2008, VA medical records document that the Veteran started arguments with his spouse and would break things around the house. The Veteran denied wanting to hurt himself or others. An earlier August 8, 2008 VA phone record documented a report of his wife striking him. A December 2009 VA medical provider found the Veteran to have problems with memory, wandering and abnormal behavior status post surgery for glioblastoma. The examiner indicated that the behavioral issues were consistent with dementia. A January 2010 VA addendum notes that the Veteran's wife reported that the Veteran had memory problems and had difficulty with math. The Veteran's wife reported that she feared that the Veteran was depressed and hopeless due to his condition, but the Veteran denied depression and attributed lack of activity to fatigue and sleepiness. The January 2010 VA medical provider noted that the Veteran was oriented to place, purpose, time and person, provided cooperative social interaction and had an "okay" mood, but constricted affect. The Veteran's thought processes were linear. The Veteran reported decreased mental clarity, indecisiveness, avoidance, irritability, hopelessness, fatigue, lack of motivation, worry and worthlessness. Following testing, the examiner found the Veteran had a relatively preserved functioning in the area of simple attention and confrontation naming. Speed of information processing, executive functioning, visuospatial abilities and visual scanning were impaired and had variable memory measures. It was noted that cognitive impairment may decline due to dementing process. A September 1, 2010 VA medical provider noted worsening depression and that the Veteran not getting out of bed or going outside. The examiner assessed depression and anxiety disorder. In September 2010, the Veteran underwent another VA examination, which focused on the period since the June 2007 VA examination. The examiner found the Veteran to be clean and casually dressed, with clear speech, cooperative attitude and blunted affect. The examiner noted anxiety and the Veteran reported severe depression for the last 10 to 15 years. The examiner found the Veteran to be intact to person, time and place with an unremarkable thought process and content. The Veteran had no delusions or hallucinations and understood the outcome of his behavior. The examiner also noted obsessive/ritualistic behavior of digging his fingernails. The Veteran wife reported a panic attack a year and a half previously. The Veteran denied suicidal or homicidal ideation. The examiner found fair impulse control and no episodes of violence. The examiner also noted that the Veteran was unable to maintain minimum personal hygiene, but that his wife was his care taker. The September 2010 VA examiner found that the Veteran had a severely impaired memory. Although the Veteran knew the amount of his monthly benefit, he did not know the amount of monthly bills or prudently handle payments. The examiner also noted that the Veteran stopped working as a truck driver following his brain tumor surgery and had difficulty verbalizing how the service-connected anxiety may have affected his occupational impairment. The Veteran was a poor historian and the record indicated that he changed jobs frequently. The examiner diagnosed the Veteran with general anxiety disorder, severe, and dementia, not otherwise specified. The examiner identified symptoms associated with dementia as severe memory problems, comprehension problems, caretaker for activities of daily living and personal hygiene, severe occupational and social impairment including unemployability and recent seizure. The examiner assigned an overall GAF score of 40, but assigned a GAF score for general anxiety disorder only of 50. An August 2011 VA medical provider found the Veteran to be alert and oriented times three, except for the date, but noted that he did know the month and year. The February 2012 VA medical opinion provider found that it was highly unlikely, much less than a 50/50 possibility, that the Veteran's brain tumor was present either before service or during his service; rather, he found the tumor to be consistent with a fast-growing malignant tumor, which has a usual course of only one to three years. III. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (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 Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is undertaken with the possibility that "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) may be warranted. Historically, in an August 1998 rating decision, the RO awarded service connection and assigned an initial 10 percent rating for general anxiety disorder, effective March 17, 1998. The Veteran filed a claim for increased rating in January 2006, and in the June 2006 rating decision on appeal, the RO awarded the Veteran a 50 percent rating.. Although the ratings for the Veteran's general anxiety disorder have been assigned under Diagnostic Code 9400, , the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the formula, a 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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 inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; 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 closes relatives, own occupation, or own name. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. The Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) explains GAF as a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." A GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). At the outset, the Board notes that, in addition to a service-connected general anxiety disorder, the medical evidence reflects diagnoses of depression, PTSD and dementia. Where it is not possible to distinguish the effects of nonservice-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As there is no indication here that it is possible to distinguish the symptoms of general anxiety disorder, depression and PTSD due to childhood molestation, the Board has considered all of the psychiatric symptoms for those disabilities in evaluating his service-connected general anxiety disorder. However, during this appeal the Veteran was diagnosed with a brain tumor in 2007. That tumor was operatively removed in August 2007. As noted by the September 2010 VA examiner, the Veteran has dementia associated with the brain tumor. The September 2010 VA examiner further found that the psychiatric symptoms associated with the dementia due to brain tumor and brain surgery included: severe memory problems (remote, recent and immediate), comprehension problems, need for caretaker for activities of daily living and personal hygiene, severe occupational and social impairment including unemployability and recent seizure. The September 2010 VA examiner also noted that it was "within the realm of possibility that the recurrent headaches documented...service records were an early symptom of a slowly growing brain tumor that became more severe...years later." The September 2010 VA examiner, however, reported that he would defer to an expert in regards to whether the brain tumor (and thus dementia) started in service. The AMC subsequently obtained a VA medical opinion in February 2012, which included a review of the claims file. The February 2012 VA neurosurgeon found that "it is highly unlikely, much less than 50/50 possibility that the veteran's brain tumor was present either before...service...or during...service. The pathology of the tumor is consistent with a fast-growing malignant tumor which usually has a course of only 1 to 3 years." The September 2010 VA examiner provided, at best. a speculative opinion that the Veteran's brain tumor (and thus dementia) is related to service. The law provides that service connection may not be based on resort to speculation or remote possibility. 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). Additionally, the September 2010 VA examiner specifically noted that he would defer to the opinion of a specialist on that matter. The VA neurosurgeon that provided the February 2012 VA medical opinion was a specialist and specifically found that the Veteran's tumor did not develop in service, but rather decades following service. The September 2010 VA examiner also identified certain symptoms/problems attributable to Veteran's nonservice-connected dementia-in particular, severe memory problems, comprehension problems, the need for a caretaker for activities of daily living and personal hygiene, seizures and unemployability. Competent, persuasive evidence thus indicates that the manifestations of service-connected general anxiety and nonservice-connected dementia are distinguishable; as such, symptoms associated with, and the level of impairment resulting from, the brain tumor and subsequent dementia will not be considered for rating purposes. Considering the pertinent evidence of record in light of the above, the Board finds that, for the period prior to September 21, 2010, the competent, probative evidence reflects that the Veteran's general anxiety disorder symptoms, including psychiatric symptoms that cannot be distinguished from his depression and PTSD due to childhood molestation, are consistent with no more than the 50 percent rating assigned. For this period, the medical evidence reflects that the Veteran's psychiatric symptoms attributable to, or indistinguishable from, his service-connected general anxiety disorder wee n objectively manifested, primarily, by anxious and depressed mood and difficulty in establishing effective work and social relationships. Prior to September 21, 2010, the Veteran's psychiatric symptoms did not meet, nor more nearly approximate type and severity of psychiatric symptoms warranting at least the next higher, 70 percent, rating. As noted above, under the General Rating Formula, the 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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 inability to establish and maintain effective relationships. However, the objective medical evidence does not show such symptoms as suicidal ideation (although the Veteran occasionally reported suicidal ideation without intent, the majority of the evidence documented the Veteran's repeated denials of such); speech intermittently illogical, obscure or irrelevant (with findings of normal speech by the March 2006 and June 2007 VA examiners; spontaneous but terse speech by an April 2008 VA medical provider; pressured speech by a June 2008 VA medical provider; and clear speech by the September 2010 VA examiner); impaired impulse control such as unprovoked irritability with periods of violence (the January 2006 VA medical provider found good impulse control and the September 2010 VA examiner found fair impulse control), with no episodes of violence; spatial disorientation; impaired abstract thinking; impaired judgment (organized, linear thoughts found by January 2006 VA medical provider, June 2007 VA examiner found normal thought process, intact judgment and no difficulty understanding simple commands); or inability to establish and maintain effective work relationships (the March 2006 VA examiner found difficulties maintaining effective work and social relationships, but not inability; in his June 2007 VA examination the Veteran reported that he had had a fair relationship with his supervisors and coworkers; the Veteran has been married throughout the appeal period and the September 2010 VA examiner noted the loyalty and support of the Veteran's wife) that are characteristic of the 70 percent rating. The medical evidence of record for this period indicates that, the Veteran did not have near-continuous panic or depression affecting ability to function independently, appropriately and effectively. During the March 2006 VA examination, the Veteran reported that he was not excessively anxious and had only partial anhedonia; his mood was "okay". During the June 2007 VA examination the Veteran reported constant anxiety on an almost daily basis and the examiner found him to have occasional difficulty performing activities of daily living. However, the Veteran also returned to work in June 2007 and only stopped working in August 2007 due to the discovery of his brain tumor, indicating that he was capable of performing activities of daily living, including working at that time. The medical evidence of record pertinent to this period also varies as to whether the Veteran had obsessional rituals. The March 2006 VA examiner noted a report of some obsessive rituals, such as checking his alarm time repeatedly. However, the June 2007 VA examiner found no ritualistic obsession. An April 2, 2008 VA medical provider found possible obsessive traits and an April 16, 2008 VA medical record documented that the Veteran reported hitting and cutting himself to relax. Collectively, the aforementioned medical evidence reflects that, the psychiatric symptoms attributable to, or indistinguishable from, his general anxiety disorder, were indicative of no more than occupational and social impairment with reduced reliability and productivity-the level of occupational and social impairment consistent with no more than the currently assigned 50 percent disability rating. The Board further finds that none of the GAF scores assigned at any pertinent point prior to September 21, 2010 provides a basis for assigning a higher rating. As indicated, the Veteran was assigned the score of 55 by the March 2006 and June 2007 VA examiners. Under the DSM-IV, GAF scores from 51 to 60 are indicative of 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). The Board finds that the assigned GAF scores of 55, reflecting moderate symptoms or moderate overall impairment, are consistent with no more than the 50 percent rating assigned from January 26, 2006. In fact, as such scores suggest even less occupational and social impairment than that contemplated in the assigned, 50 percent rating; as such, these scores clearly provide no basis for assignment of an even higher rating. In any event, as noted above, the Board emphasizes that a GAF score is not dispositive of the evaluation question; rather as indicated above, the symptoms shown provide the primary basis for an assigned rating. Here, as indicated above, the Veteran primarily exhibited symptoms typically associated with a 50 percent rating. Under the circumstances of this case, the Board finds that pertinent to the January claim for increase, and prior to September 1, 2010, the Veteran's psychiatric symptoms did not meet, nor nearly approximate, the criteria for at least a 70 percent rating. See 38 C.F.R. § 4.7. As the criteria for the next higher, 70 percent, rating are not met for that time period, it follows that the criteria for the maximum, 100 percent rating likewise are not met. However, the Board also finds that, resolving all reasonable doubt in the Veteran's favor, as of the date of a September 1, 2010 VA medical record, the evidence reflects a worsened psychiatric disability picture warranting a 70 percent, but no higher, rating for general anxiety disorder. As of this date, medical evidence reflects that he has suffered from obsessional rituals which interfere with routine activities and near continuous depression. He has also experienced strained family relationships. The September 1, 2010 VA medical provider found that the Veteran's depression had worsened and that the Veteran was not getting out of bed or going outside. The examiner also noted anxiety and obsessive/ritualistic behavior of digging his fingernails. The examiner assessed the general anxiety disorder as severe. Also, during his September 2010 VA examination, the Veteran complained of moderate to severe anxiety daily and severe depression. The September 2010 VA examiner assigned a GAF score of 50 (attributable only to the general anxiety disorder as opposed to the GAF score of 40 attributed to the Veteran's overall condition). Under the DSM-IV, GAF scores 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). Considering this, the assigned GAF score of 50 deemed to represent the level of impairment for the general anxiety disorder, is also suggestive of a higher rating. Although the Veteran has continued to evidence numerous symptoms more consistent with a 50 percent disability rating, giving the Veteran the benefit of the doubt, the Board finds that the VA medical evidence demonstrates that since the Veteran experienced a level of psychiatric impairment marked by the occupational and social impairment with deficiencies in most areas. As such, his level of impairment is considered consistent with the assigned 70 percent rating. At no point pertinent to this appeal have the Veteran's overall psychiatric symptoms attributable to, or indistinguishable from, his service-connected general anxiety disorder reflected the type or severity of symptoms warranting a 100 percent rating under the General Rating Formula. Indeed, the Veteran has not been shown to display such symptoms as gross impairment in thought processes or communication; persistent hallucinations or delusions; 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 closes relatives, own occupation, or own name. At all pertinent points, the Veteran has been able to communicate easily and demonstrated clear thought processes. He has repeatedly denied delusions and hallucinations, other than his single report of corner of the eye illusions. The majority of the evidence also documents repeated denials of suicidal and homicidal ideation. The Veteran has also repeatedly demonstrated that he was oriented to time and place. His intermittent inability to perform activities of daily living and memory loss has been attributed to his nonservice-connected dementia. Accordingly, the Board finds that, since September 2010, when considering the complete picture of the Veteran's psychiatric symptomatology with the exception of that attributable to dementia, the Board finds that, a 70 percent, but no higher rating, is warranted. See 38 C.F.R. § 4.7. The criteria for the maximum, 100 percent rating simply are not met at point pertinent to this appeal. The Board emphasizes that, in analyzing this claim, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant a higher rating for a psychiatric disability. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). As for the lay assertions of record, the Board notes that the Veteran is certainly competent to report matters within his personal knowledge, to include his own symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In this case, the Veteran has complained of the severity of his psychiatric symptoms. Even if so, however, the Board points out that, as a layperson without appropriate medical training and expertise to competently render the medical findings needed to support a higher rating, his assertions would not be considered more persuasive than the findings of a qualified medical professional-here the VA examiners and medical providers. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ('a layperson is generally not capable of opining on matters requiring medical knowledge'). 38 C.F.R. § 3.159 (a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). The above determinations are based upon consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point pertinent to this appeal has the Veteran's service-connected general anxiety disorder been shown to be do exceptional or unusual to warrant any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the February 2008). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a comparison between the level of severity and symptomatology of the service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as 'governing norms.' Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) governing norms include marked interference with employment and frequent periods of hospitalizations). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether the claimant's disability picture requires the assignment of an extra-schedular rating. Id. at 116. The Board finds that schedular criteria are adequate to rate the Veteran's general anxiety disorder at all times pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and there is no medical indication or argument that the applicable criteria are inadequate to rate the disability under consideration at any pertinent point. The Veteran has asserted that he had some difficulties working due to general anxiety disorder, but such difficulties were contemplated by the rating criteria. Additionally, the Veteran stopped working due to his non-service-connected brain tumor and the September VA examiner found the Veteran to be unemployable due to his non-service-connected dementia. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As a final point, the Board notes that, although a claim for a total disability rating based on individual unemployability (TDIU) may be considered a component of a claim for higher rating (see e.g., Rice v. Shinseki, 22 Vet. App. 447 (2009)), here, there is no assertion or indication that the Veteran's general anxiety disorder renders him unemployable. Indeed, the record shows that the Veteran returned to work in June 2007, but was permanently disabled after the August 2007 discovery of his nonservice-connected brain tumor. Additionally, the September 2010 VA examiner attributed the Veteran's unemployability to his nonservice-connected dementia. The Board further notes that, during the course of this appeal, the RO denied a TDIU in a December 2008 rating decision, but the Veteran did not appeal that denial. Under these circumstances, the matter of the Veteran's entitlement to a TDIU due to the service-connected general anxiety disorder has not reasonably been raised, and need not be addressed. For all the foregoing reasons, the Board concludes that a disability rating in excess of 50 percent for general anxiety disorder is not warranted prior to September 21, 2010, but that, affording the Veteran the benefit of the doubt, a 70 percent but no higher rating for the disability is warranted from September 21, 2010. (CONTINUED ON NEXT PAGE) ORDER A disability rating in excess of 50 percent for general anxiety disorder, prior to September 21, 2010, is denied. A 70 percent disability rating for general anxiety disorder, from September 21, 2010, is granted, subject to the legal authority governing the payment of VA compensation. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs