Citation Nr: 1319019 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 10-06 725 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to an increased evaluation for service-connected general anxiety disorder, rated as 10 percent disabling prior to August 1, 2011; 30 percent disabling from August 1, 2011, to November 15, 2012; and 50 percent disabling since November 15, 2012. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran served on active duty from March 1943 to December 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran was afforded a video conference hearing before the Board in July 2012. A transcript has been associated with the claims folder. In August 1, 2012, the Board remanded this case for additional development. In a subsequent rating decision in April 2013, the AMC increased the 30 percent rating for generalized anxiety disorder to 50 percent disabling effective from November 15, 2012. Although higher ratings have been assigned for the Veteran's generalized anxiety disorder, as reflected in the November 2011 and April 2013 rating actions, the issue remains in appellate status as the maximum rating has not been assigned. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a) (2) (West 2002). FINDINGS OF FACT 1. For the period prior to August 1, 2011, the Veteran's service-connected anxiety reaction is manifested by no more than 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. 2. For the period from to August 1, 2011 to November 15, 2012, the Veteran's service-connected anxiety reaction is manifested by no more than 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 anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 3. For the period from November 15, 2012, the Veteran's service-connected anxiety reaction is manifested by no more than occasional 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; difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. For the period prior to August 1, 2011, the criteria for a rating in excess of 10 percent for anxiety reaction have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). 2. For the period from August 1, 2011, to November 15, 2012, the criteria for a rating in excess of 30 percent for anxiety reaction have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). 3. For the period from November 15, 2012, the criteria for a rating in excess of 50 percent for anxiety reaction have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA letter dated in October 2008 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Additionally, the letters informed the Veteran how disability ratings and effective dates are assigned. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board also concludes VA's duty to assist has been satisfied. The Veteran's available service treatment records and relevant VA and private medical records are in the claims folders. All records identified by the Veteran as relating to this claim have been obtained, to the extent possible. The Board finds that the record contains sufficient evidence to make a decision on the claim. VA has fulfilled its duty to assist. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with VA examinations with regard to his service-connected anxiety reaction, to include most recently in November 2012. There is no objective evidence indicating that there has been a material change in the severity of this service-connected disability since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The Board finds that the examinations in this case are adequate upon which to base a decision with regard to this claim and that a new VA examination need not be conducted at this time. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board notes that, 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/Decision Review Officer (DRO) who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issue on appeal during the hearing. Additionally, it is clear from the Veteran's testimony that he had actual knowledge of the elements that were lacking to substantiate his claim. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c) (2), nor has either 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. 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). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). In such cases, however, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that the Veteran's service-connected anxiety reaction is evaluated under Diagnostic Code 9400. The regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130 (2012). Ratings are assigned according to the manifestation of particular symptoms; however, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See 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 disability 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). The criteria for a 10 percent rating are as follows: 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. A 30 percent rating requires 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). In the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also, Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. The Veteran is seeking entitlement to an increased evaluation for service-connected anxiety reaction, which is evaluated as 10 percent disabling prior to August 1, 2011; 30 percent disabling from August 1, 2011, to November 15, 2012; and, 50 percent disabling from November 15, 2012. Historically by rating action in November 2001, service connection for a generalized anxiety disorder was granted, and a 10 percent evaluation was assigned effective from May 14, 2001. The Veteran filed the current claim for an increased rating in September 2008. The Board notes that the Veteran underwent a VA examination in December 2008. The examiner reviewed the VAMC records. The Veteran served during WWII. He had no history of any psychiatric hospitalization and was not under psychiatric care. He did not use drugs or alcohol. The Veteran had been diagnosed as having a generalized anxiety disorder felt to be secondary to his WWII trauma. His symptoms were of moderate severity since the mid 1940s with no remissions, but then again no treatment either. It was noted that he kept himself busy and according to his wife it was more from nervous energy. He enjoyed target shooting and church which was his primary source of social support. He had a group of friends and was helping to raise his 15-year-old grandson who was living at his house. He took him to school and helped with homework. He often had home bible study and helped around the house. He liked shopping and watching TV. He retired in 1993 and had not worked since. He reported irritability secondary to pain; sensitivity to heightened noises; exaggerated startle response; and, a lot of nervous energy. He had no depression, intrusive thoughts, or impaired sleep. The Veteran presented as pleasant and cooperative, appearing younger than his age. There was no evidence of depression, thought or communication impairment, delusions or hallucinations, psychosis, impairment of impulse control or sleep, inappropriate behavior, or memory difficulty. There was no evidence of panic symptoms, but he certainly had anxiety on a regular basis. His hygiene was excellent. He was oriented. He had normal rate and flow of speech. The examiner noted no change since the last VA examination 4 years prior. The Veteran had no functional limitations whatsoever. The diagnosis was generalized anxiety disorder, and a GAF of 65 was assigned. The examiner opined that the Veteran's mental disorder signs and symptoms were relatively mild. He was still working and would experience decreased work efficiency and some difficulty with performing his occupational tasks only during periods of significant stress. The Veteran underwent a VA examination in October 2009. The Veteran reported chronic and excessive worry and anxiety. The examiner noted the Veteran was very pleasant and cooperative. He led a very active social life and had a solid social support system. There was no history of psychiatric hospitalization, and he was not under any current psychiatric care. The examiner noted no changes since the previous VA examination. The Veteran reported his symptoms began in service in 1943. He reported constant excessive worry which affected his total daily functioning and resulted in insomnia. The examiner noted this was disputed by the medical records which noted his sleep was disrupted due to urinary tract problems and increased muscle tension. His treatment included Prozac and gapentin with minimal response and his condition had remained unchanged. He reported a history of psychiatric hospitalization twice many years ago, but no date was given. The examiner noted that the Veteran was not a reliable historian. The Veteran's reports of two psychiatric hospitalizations for, "nervous breakdowns" were not supported by the medical records. He also reported treatment with psychotropic drugs but there was no report of any current psychotropic medications on review of the medical records. Sleep as noted was not impaired by psychiatric problems but due to urinary tract problems. The examiner noted that the Veteran presented as oriented within normal limits. Appearance, hygiene, and behavior were appropriate. Eye contact was good. Affect and mood showed anxiety. Communications, speech, and concentration were within normal limits. Panic attacks and suspicion were absent. There was no history of delusions or hallucinations, or obsessional rituals, and none were observed on examination. Thought process was appropriate. He was able to read and to understand directions. He had no slowness of thought nor did he appear confused. Judgment and memory were not impaired. Suicidal and homicidal ideation was absent. The diagnosis was generalized anxiety disorder, unchanged. A GAF of 70 was assigned. The examiner noted that the Veteran was capable of handling his own financial affairs. There was no major sign of cognitive impairment and there was no history of mismanagement of his financial affairs. He had no difficulty performing activities of daily living. He was able to establish and maintain effective work/school and social relationships. The examiner described the Veteran's condition as mild or transient causing occasional and social impairment with decrease in work efficiency and occasional tasks only during periods of significant stress. The Veteran underwent a VA examination on August 1, 2011. The examiner noted that the Veteran had only one mental disorder-generalized anxiety reaction. The examiner described the Veteran's condition as fairly stable with little change in function. It was mild or transient but caused occasional and social impairment with decrease in work efficiency and occasional tasks only during periods of significant stress. The examiner noted the Veteran lived in his own home. His disabled son lived with him for the previous five years; along with the Veteran's 18-year-old grandson. The Veteran got along well with his wife. The Veteran had been retired since 1993. The Veteran had not had any formal mental health treatment for his anxiety disorder. He reportedly coped with stress by praying and exercise. The Veteran presented with anxiety, chronic sleep impairment, mild memory loss, and difficulty in adapting to stressful circumstance. No other symptoms of mental disorders were noted. The diagnosis was generalized anxiety disorder, unchanged, and a GAF of 65 was assigned. The examiner noted that the Veteran was capable of handling his own financial affairs. The Veteran underwent a VA examination in November 15, 2012. The claims file and statements from the Veteran's wife were reviewed. The examiner noted that the Veteran had only one mental disorder-generalized anxiety reaction. The Veteran reported that he was jumpy when he heard loud noises and had "a rapid heartbeat" and shortness of breath. He reported this was a daily occurrence. He was a worrier particularly about his family. He found solace in prayer and religion. The Veteran enjoyed target shooting in his back yard. He had been retired since 1993. The examiner noted the Veteran lived in his own home with his wife, disabled son, and with his 18-year-old grandson. The Veteran was actively involved with his church. He had friends and continued to attend social functions. He reported having a nervous breakdown and being hospitalized around 1960 in Sioux City. He did not recall much about the circumstances. He reported again being hospitalized in the 1970s in Sioux City for six weeks. The examiner noted that he could find no evidence of these reported hospitalizations. He had apparently had no other history of any psychiatric hospitalizations. He was treated with Prozac in 2005 but has no other history of outpatient psychiatric or follow up treatment. The Veteran presented with anxiety and panic attacks more than once a week; near continuous panic or depression affecting the ability to function; and mild memory loss. No other symptoms of mental disorders was noted. The examiner noted that the veteran was capable of handling his own financial affairs. The examiner reported that he had reviewed the Veteran's claims file as well as performed an interview with the Veteran and his wife. The examiner opined that the Veteran's current GAF was 65. He had some social impairment related to his sensitivity to loud noises in that he was jumpy and tried to isolate in order to regain his composure. He reported that these episodes lasted 30 minutes or so and he could regain some control pretty quickly. He also experienced some stress related to interpersonal conflicts at home with his son and grandson; however he continued to have a strong marriage and good relations with all of his children. He had remained active in his church. He had had an excellent work history and his occupational capabilities had not really been impacted. In addition to reacting to loud noises, the Veteran's primary stressors were from his adult children who were struggling financially. The examiner's impression was that the Veteran's function had been stable since he had last reviewed the Veteran's psychiatric function in 2001. Upon review of the evidence of record, the Board concludes that the Veteran's anxiety reaction is properly evaluated as 10 percent disabling prior to August 1, 2011; as 30 percent disabling from August 1, 2011, to November 15, 2012; and as 50 percent disabling since November 15, 2012. a. Increased evaluation for general anxiety disorder, rated as 10 percent disabling prior to August 1, 2011. The Veteran filed the current claim for an increased rating in September 2008. He underwent two VA examinations during this time period, in December 2008 and October 2009. The examination reports noted that the Veteran's generalized anxiety disorder symptoms were of moderate severity since the mid 1940s with no remissions and with no treatment. The December 2008 examiner noted no change since the prior VA examination four years earlier. The October 2009 examiner also noted no change since the prior VA examination. The Veteran presented as pleasant and cooperative. His eye contact was good. Affect and mood showed anxiety. He was oriented, and communications, speech, and concentration were within normal limits. Panic attacks, depression, and suspicion were absent. There was no history of delusions, hallucinations, or obsessional rituals, and none were observed on examination. Thought process was appropriate. He was able to read and to understand directions. He had no slowness of thought nor did he appear confused. Judgment and memory were not impaired. Suicidal and homicidal ideation was absent. There was no evidence of depression, thought or communication impairment, delusions or hallucinations, inappropriate behavior, psychosis, impairment of impulse control or sleep, or memory difficulty. The Veteran had no functional limitations whatsoever. The diagnosis was generalized anxiety disorder and GAFs of 65 and 70 were assigned. The examiner noted that the Veteran was capable of handling his own financial affairs. He had no difficulty performing activities of daily living. He was able to establish and maintain effective work/school and social relationships. The examiner described the Veteran's condition as mild or transient causing occasional and social impairment with decrease in work efficiency and occasional tasks only during periods of significant stress. The Board has considered whether the Veteran meets the criteria for an evaluation in excess of 10 percent at any time during the period prior to August 1, 2011. In this regard, the Board notes that the Veteran did not exhibit occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks 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). In fact, the Board finds that during the period prior to August 1, 2011, the Veteran's service-connected general anxiety syndrome exhibited symptoms which were no more than mildly disabling. The Veteran was able to perform all of his functions of daily living with only mild or transient symptoms causing occasional social impairment with decrease in work efficiency and tasks only during periods of significant stress continue functioning. In addition, the evidence of record does not reflect that the Veteran's anxiety reaction manifested during this time period by the bulk of symptoms set forth as examples under that criteria, such as depressed mood, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). For these reasons, the Board concludes that an evaluation in excess of 10 percent is not warranted for the period prior to August 1, 2011. b. Increased evaluation for service-connected general anxiety disorder, rated as 30 percent disabling from August 1, 2011, to November 15, 2012. In the August 1, 2011, VA examination it was noted that the Veteran's condition was fairly stable with little change in function. It was mild or transient but caused occasional and social impairment with decrease in work efficiency and occasional tasks only during periods of significant stress. The Veteran lived in his own home with his wife, his disabled son, and his grandson. He presented with anxiety, chronic sleep impairment, mild memory loss, and difficulty in adapting to stressful circumstance. No other symptoms of mental disorders were noted. The diagnosis was generalized anxiety disorder, unchanged. A GAF of 65 was assigned. The examiner noted that the Veteran was capable of handling his own financial affairs. The Board finds that during the period from August 1, 2011, to November 15, 2012, the Veteran's service-connected general anxiety syndrome did not at any time exhibit 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; difficulty in establishing and maintaining effective work and social relationships. In fact, the Veteran was noted as having presented fairly stable symptoms with little change in function. His general anxiety syndrome was described as mild or transient. In addition, the evidence of record does not reflect that the Veteran's anxiety reaction manifested during this time period by the bulk of symptoms set forth as examples under that criteria, such 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Although the Board has considered assigning the Veteran's anxiety reaction a 50 percent evaluation for the period from August 1, 2011, to November 15, 2012, the Board does not find that it is factually ascertainable by the medical evidence of record that during this period that the disability resulted in the degree of reduced reliability and productivity contemplated by a 50 percent rating. In addition, there is no indication in the evidence of record that the Veteran's anxiety reaction caused circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective work and social relationships. As such, the Board finds that it is not factually ascertainable from the evidence of record that the Veteran's anxiety reaction more nearly approximated the criteria for a 50 percent evaluation during the period from August 1, 2011, to November 15, 2012, and, therefore, an evaluation in excess of 30 percent is not warranted for the period from August 1, 2011, to November 15, 2012. c. Increased evaluation for service-connected general anxiety disorder, rated as 50 percent disabling since November 15, 2012. At the November 15, 2012, VA examination, the Veteran was noted to have some social impairment related to his sensitivity to loud noises in that he was jumpy and tries to isolate in order to regain his composure; however, the Veteran also enjoyed target shooting in his back yard. He experienced some stress related to interpersonal conflicts at home with his son and grandson; however, he lived in his own home, with his wife, disabled son, and grandson. He continued to have a strong marriage and good relations with all of his children. He was actively involved with his church, had friends, and attended social functions. Prior to retiring, he had an excellent work history and his occupational capabilities had not really been impacted. In addition to reacting to loud noises the Veteran's primary stressors were from his adult children who were struggling financially. The examiner's impression was that the Veteran's function had been stable since he had last reviewed the Veteran's psychiatric function in 2011. The Veteran was capable of handling his own financial affairs. The examiner opined that the Veteran's current GAF was 65. By rating action in April 2013, the AMC increased the 30 percent evaluation for the service-connected general anxiety disorder to 50 percent disabling since November 15, 2012. The Board finds that during the period from November 15, 2012, the Veteran's service-connected general anxiety syndrome did not at any time exhibit 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 worklike setting); inability to establish and maintain effective relationships. Although the Board has considered assigning the Veteran's anxiety reaction a 70 percent evaluation for the period from November 15, 2012, the Board does not find that it is factually ascertainable by the medical evidence of record that during this period that the disability resulted in the degree of reduced reliability and productivity contemplated by a 70 percent rating. In addition, there is no indication in the evidence of record that the Veteran's anxiety reaction caused 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 worklike setting); inability to establish and maintain effective relationships. As such, the Board finds that it is not factually ascertainable from the evidence of record that the Veteran's anxiety reaction more nearly approximated the criteria for a 70 percent evaluation during the period from November 15, 2012, and, therefore, an evaluation in excess of 50 percent is not warranted for the period from November 15, 2012. GAF Scores In rendering the aforementioned decisions, the Board has taken into account that the Veteran's GAF scores have been recorded as ranging from 65 to 70. A GAF score ranging from 61 to 70 indicates 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, has some meaningful interpersonal relationships. A GAF score ranging from 51 to 60 indicates 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 peer or coworkers). A GAF score of 41 to 50 indicates serious symptoms and serious impairment in social, occupational, or school functioning (e.g., no friends), while a GAF score of 31 to 40 indicates major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). See Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV) The Board has considered the Veteran's GAF scores and finds that the ratings assigned to the Veteran's anxiety reaction adequately compensate the Veteran for his symptoms. The Board notes that the Veteran was assigned a GAF score of 70 at the October 2009 VA examination; at the December 2008, August 2011, and November 2012 VA examinations the Veteran was assigned GAF scores of 65. Therefore, for the entire period on appeal the Veteran's GAF score was recorded at no less than 65, the Veteran has been assigned first a 10 percent rating (prior to August 1, 2011; a 30 percent rating from August 1, 2011, to November 15, 2012; and a 50 percent rating from November 15, 2012, to the present. The Board has considered the Veteran's GAF scores which are indicative of some mild symptoms, but generally functioning pretty well, and having some meaningful interpersonal relationships; and finds that the symptoms associated with the Veteran's anxiety reaction are appropriately compensated by the 10 percent rating (prior to August 1, 2011; 30 percent rating from August 1, 2011, to November 15, 2012; and 50 percent rating from November 15, 2012, to the present. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected anxiety reaction is inadequate. A comparison between the level of severity and symptomatology of the Veteran's anxiety reaction with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. There is no evidence in the medical records of an exceptional or unusual clinical picture. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. In summary, the Board concludes that the preponderance of the evidence is against the claims for a rating higher than 10 percent prior to August 1, 2011; higher than 30 percent from August 1, 2011, to November 15, 2012; and higher than 50 percent from November 15, 2012, to the present. The benefit-of-the-doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application as there is not an approximate balance of evidence. See Ortiz v. Principi, 274 F. 3d 1361(Fed. Cir. 2001). Assignment of staged ratings has been considered and applied appropriately. ORDER Entitlement to an evaluation in excess of 10 percent for service-connected anxiety reaction for the period prior to August 1, 2011, is denied. Entitlement to an evaluation in excess of 30 percent from August 1, 2011, to November 15, 2012, is denied. Entitlement to an evaluation in excess of 50 percent for service-connected anxiety reaction for the period of November 15, 2012, to the present is denied. ____________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs