Citation Nr: 1320833 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 09-23 611 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a cervical spine disorder. 2. Entitlement to an initial disability rating greater than 30 percent for the service-connected major depressive disorder prior to May 19, 2008. 3. Entitlement to an initial disability rating greater than 70 percent for the service-connected major depressive disorder beginning on May 19, 2008. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) by reason of service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veteran WITNESSES AT HEARINGS ON APPEAL The Veteran and her sister ATTORNEY FOR THE BOARD Paul S. Rubin, Counsel INTRODUCTION The Veteran had active service in the U.S. Army from December 1980 to April 1981 and from July 1981 to December 1986. She also had active service in the U.S. Air Force from January 2003 to August 2004. She also served in the Florida Army National Guard and Army Reserve with various periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA) from 1986 to 2005. The issues on appeal initially came to the Board of Veterans' Appeals (Board) from a June 2007 rating decision issued by the RO. In a January 2010 rating decision, VA judged the Veteran as incompetent for purposes of managing VA payments. See 38 C.F.R. § 3.353(a) (2012). The Veteran's sister was named as guardian. In November 2010, the Veteran presented testimony at a hearing held at the RO before a Veterans Law Judge who has since retired. In February 2013, the Veteran presented testimony at a hearing held at the RO before the undersigned Veterans Law Judge. See 38 C.F.R. § 20.707 (2012) (the Board member who conducts the hearing will participate in making the final determination of the claim). Transcripts of both hearings are associated with the claims file. In July 2010, February 2011 and June 2012 the Board remanded the case to the RO for additional development. After completion of this development by the RO, the case was returned to the Board for the purpose of appellate disposition. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records dated from 2011 to 2013, which are pertinent to the present appeal. However, these records were reviewed by the RO. The claim for a TDIU rating is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on her part. FINDINGS OF FACT 1. Although there is clear and unmistakable evidence that cervical spine degenerative disc disease preexisted service, there is no clear and unmistakable evidence that cervical spine degenerative disc disease was not aggravated by service. In fact, there is probative evidence suggesting in-service aggravation of preexisting cervical spine degenerative disc disease from January 2003 to August 2004. The presumption of soundness has not been rebutted. 2. There is probative medical and lay evidence showing the Veteran has current cervical spine degenerative disc disease and arthritis as likely as not is related to her period of active duty service from January 2003 to August 2004. 3. Prior to May 19, 2008, the service-connected major depressive disorder is shown to have been manifested by such symptoms as frequent depression and anxiety, anger and irritability, social isolation, "anxious" or "constricted" or "flat" or "tense" affect, slowed speech, low confidence, decreased interest, decreased energy, panic attacks (at times more than once a week), poor concentration, low frustration tolerance, crying spells, chronic sleep impairment, forgetfulness with tasks, and short and long term memory impairment (at times), and psychiatric symptomatology often described as "moderate." Her symptoms are shown to more nearly approximate a level of occupational and social impairment with reduced reliability and productivity. 4. Beginning on May 19, 2008, the service-connected major depressive disorder is shown to have been manifested by such symptoms as near-continuous panic or depression, anxiety, mood swings, frequent panic attacks, some suicidal thoughts, evidence of losing consciousness due to alcohol use, impaired impulse control, irritability, neglect of personal hygiene and appearance at times, difficulty in adapting to stressful circumstances, memory impairment, difficulty concentrating, social impairment, and several instances of inpatient treatment. Her symptoms are shown to more nearly approximate a level of occupational and social impairment manifested by deficiencies in most areas. CONCLUSIONS OF LAW 1. By extending the benefit of the doubt to the Veteran, her disability manifested by cervical spine degenerative disc disease is due to disease or injury was incurred in active service. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2012); VAOPGCPREC 3-03 (July 16, 2003); Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). 2. Prior to May 19, 2008, the criteria for the assignment of an initial disability rating of 50 percent, but no greater, for the service-connected major depressive disorder have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.21, 4.126, 4.130 including Diagnostic Code 9434 (2012). 3. Beginning on May 19, 2008, the criteria for the assignment of an initial disability rating greater than 70 percent for the service-connected major depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.21, 4.126, 4.130 including Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist For the issue of service connection for a cervical spine disorder, review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The duty to notify was accomplished by way of a VCAA letter from the RO to the Veteran dated in November 2006. In any event, since the Board is granting the service connection issue, there is no need to discuss whether there has been compliance with the notice and duty to assist provisions of VCAA because even if, for the sake of argument, there has not been, this is inconsequential and, therefore, at most harmless error. See 38 C.F.R. § 20.1102; Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). For the higher initial rating issues for a major depressive disorder, review of the claims folder also reveals compliance with the VCAA. Specifically, the November 2006 letter effectively satisfied the notification requirements of the VCAA consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) by: (1) informing her about the information and evidence not of record that was necessary to substantiate higher initial rating issues; (2) informing her about the information and evidence the VA would seek to provide; (3) informing her about the information and evidence she was expected to provide. See also Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In addition, the November 2006 letter from the RO further advised the Veteran of the elements of a disability rating and an effective date, which are assigned when service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). This appeal arises from disagreement with the initial evaluation following the grant of service connection for major depressive disorder in a June 2007 rating decision. Both the U.S. Court of Appeals for Veterans Claims (Court) and the Federal Circuit Court of Appeals have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With regard to timing, the Court and Federal Circuit Court have held that VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (Mayfield II); Pelegrini II, 18 Vet. App. at 120. In the present case, the RO issued all required VCAA notice prior to the June 2007 rating decision on appeal. Thus, there is no timing error. Accordingly, prejudicial error in the timing or content of VCAA notice has not been established as any defect was not outcome determinative. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). With respect to the duty to assist, the RO has secured the Veteran's service treatment records (STRs), service personnel records (SPRs), National Guard and Reserve records, VA inpatient and outpatient treatment records, post-service military clinic records, and Social Security Administration (SSA) disability records. For her part, the Veteran has submitted personal statements, duplicate medical evidence, additional VA treatment records, hearing testimony, and representative argument. The Veteran was also afforded April 2007, August 2009, and December 2011 VA psychological examinations to rate the current severity of her major depressive disorder. The need for a more contemporaneous examination occurs only when the evidence indicates that the current rating may be incorrect or when the evidence indicates there has been a material change in the disability. See 38 C.F.R. § 3.327(a); Palczewski v. Nicholson, 21 Vet. App. 174, 182-83. Here, the December 2011 VA examination is recent in time. All of the VA examinations, taken as a whole, are fully sufficient to evaluate the appeal. Also, the Board is granting an initial 50 percent rating for worsening of the anxiety disorder prior to May 19, 2008. In addition, no other probative medical or lay evidence demonstrates a worsening of the anxiety disorder beyond the initial 50 and 70 percent ratings currently assigned. Therefore, a new VA examination to rate the severity of the major depressive disorder is not warranted. With regard to the November 2010 and February 2013 Travel Board hearings, in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010), the Court held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues pertinent to the claim(s) on appeal and (2) suggesting the submission of evidence that may have been overlooked. See also 38 C.F.R. § 3.103(c)(2). At both hearings, the Veterans Law Judge and representative for the Veteran outlined the issue on appeal and engaged in a colloquy as to substantiation of the higher rating claim. There was a discussion with respect to the particular psychiatric signs and symptoms the Veteran exhibited, for purposes of securing higher ratings. Moreover, during the course of the appeal, the Veteran's representative has addressed the rating criteria necessary to establish higher initial ratings. Overall, the hearing was legally sufficient. Finally, the RO substantially complied with the Board's July 2010, February 2011, and June 2012 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). Specifically, pursuant to the remands, SSA disability records were secured, and the Veteran was provided a December 2011 VA examination to rate the current severity of her major depressive disorder. The RO has substantially complied with the Board's instructions. In summary, the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012). Governing Laws and Regulations for Service Connection A Veteran is entitled to compensation from the VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C.A. § 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. §§ 3.303, 3.306. Under 38 C.F.R. § 3.303(a), service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Under 38 C.F.R. § 3.303(b), with an enumerated "chronic disease" (such as hypertension) shown in service (or within the presumptive period under § 3.307), subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. See also Groves v. Peake, 524 F.3d 1306, 1309 (2008). This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity of symptomatology. 38 C.F.R. § 3.303(b). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). When an issue is raised as to whether the disorder claimed by the Veteran preexisted service, the governing law provides that every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable (obvious or manifest) evidence demonstrates that (1) an injury or disease existed before acceptance and enrollment into service (2) and was not aggravated by such service. See 38 U.S.C.A. §§ 1111, 1132, 1137; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). See also VAOPGCPREC 3-2003 (July 16, 2003). This statutory provision is referred to as the "presumption of soundness." Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). In other words, to rebut the presumption of soundness for disorders not noted on the entrance or enlistment examination, VA's General Counsel has clarified that VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003. The Court and Federal Circuit Court have adopted the General Counsel's position. Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The government may show a lack of aggravation by establishing by clear and unmistakable evidence that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). See also Wagner, 370 F.3d at 1096. If this burden is met, then the Veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under Section 1111 by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service, the Veteran's claim is one of service connection on a direct incurrence basis. Wagner, 370 F.3d at 1096. The law provides that an increase in disability must consist of worsening of the enduring disability. Davis v. Principi, 276 F.3d 1341, 1344 (Fed. Cir. 2002). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). See also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (which holds that evidence of a temporary flare-up, without more, does not satisfy the level of proof required of a non-combat Veteran to establish an increase in disability). A "lasting worsening of the condition" - that is, a worsening that existed not only at the time of separation but one that still exists currently is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the Veteran's health and medical treatment during and after military service, as evidence of whether a preexisting condition was aggravated by military service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service beyond its natural progression. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). "Clear and unmistakable evidence" is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence".) That is, the standard of proof for rebutting the presumption of soundness is not merely evidence that is "cogent and compelling, i.e., a sufficient showing, but evidence that is clear and unmistakable, i.e., undebatable ...." Vanerson, 12 Vet. App. at 261. In short, it is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In determining whether service connection is warranted based on in-service incurrence, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Analysis - Cervical Spine Disorder Upon review of the evidence of record, the Board find that service connection for cervical spine degenerative disc disease and arthritis is warranted. The Veteran asserts that she has a current cervical spine / neck disorder that was either incurred or aggravated during her final period of military service from January 2003 to August 2004, to include service in the Persian Gulf. She does not allege any cervical spine problems during her initial periods of active duty from 1980 to 1986. She has proffered several different theories as to how her cervical spine disability was incurred / aggravated by service from January 2003 to August 2004. She has stated her cervical spine disability was "expedited" by anthrax vaccines administered prior to her Persian Gulf duty. She has added that her neck "deteriorated" after her deployment to the Persian Gulf. She also has contended that her neck was injured while packing and unpacking cargo for the Persian Gulf. Finally, the Veteran asserts that her neck disorder was aggravated in 2003 during active duty when she fell off a heavy piece of equipment and hit her neck and back while on deployment in the Persian Gulf. See June 2005 Veteran's letter; February 2013 hearing testimony at pages 16-17; April 2007 VA examination at page 7; April 2009 SSA consult; September 2008 SSA medical evaluation. As mentioned, the first and perhaps most fundamental requirement for any service-connection claim is proof the Veteran currently has the claimed disability. Boyer, 210 F.3d at 1353; Brammer, 3 Vet. App. at 225. The evidence at the very least shows a current cervical spine disorder. Specifically, an April 2007 VA examiner assessed cervical spine spondylosis, subluxation, and disc narrowing per VA X-ray studies. Earlier post-service military clinic records dated in 2004 and 2005 and SSA disability records dated in 2008 and 2009 also revealed cervical spine degenerative disc disease and arthritis. Thus, the Veteran clearly has a current cervical spine disability. With regard to the existence of a cervical spine degenerative disc disease prior to her final period of active service in January 2003, an earlier March 2000 magnetic resonance imaging (MRI) report during her service in the National Guard diagnosed a herniated nucleus pulposus of the cervical spine. The National Guard records in 2000 also noted a history of "chronic" cervical spine pain. In determining whether a condition preexisted service, the Board has considered both medical and lay evidence of record. That is, the Veteran's medical history, accepted medical principles, evidence regarding the basic character, origin and development of the condition, and lay and medical evidence concerning the inception, development and manifestations of the condition was considered in accordance with VA regulation. 38 C.F.R. § 3.304(b). See also Quirin, 22 Vet. App. at 396. The evidence clearly and unmistakably demonstrates that the Veteran had a preexisting cervical spine degenerative disc disease disorder prior to her latter period of active duty service in January 2003. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). This is not in dispute. In light of this, the Board now turns to the requirement that VA must show by clear and unmistakable evidence that the Veteran's preexisting cervical spine degenerative disc disease was not aggravated by service, in order to fully rebut the presumption of soundness. Id. Upon review of the medical and lay evidence of record, the Board concludes that there is no clear and unmistakable evidence that the Veteran's preexisting cervical spine disorder was not aggravated by her second period of service from January 2003 to August 2004. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). In fact, in the present case, there is actually probative evidence suggesting in-service aggravation of a preexisting cervical spine degenerative disc disease. Overall, VA has not met its burden of proof in the instant case in terms of demonstrating that it is undebatable there was no aggravation of the cervical disc disease. The Board emphasizes that the burden of proof in aggravation cases is on VA, not the Veteran. The Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). The Veteran's credibility affects the weight to be given to his testimony and lay statements, and it is the Board's responsibility to determine the appropriate weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony." Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Board emphasizes that personal interest may affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board must analyze the credibility and probative value of the evidence, account for the evidence it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Caluza, 7 Vet. App. at 506 (citing State v. Asbury, 415 S.E.2d 891, 895 (W. Va. 1992). With regard to the evidence against aggravation, after a review of the evidence of record, the April 2007 VA examiner assessed that there was "no objective evidence to demonstrate Veteran's degenerative disc disease of c-spine was aggravated by active duty service beyond the natural progression." Notably, however, in rendering this opinion, the VA examiner failed to discuss service treatment records (STRs) dated in 2003 and 2004 that revealed chronic complaints and treatment for cervical spine degenerative disc disease. The Court has held that a VA medical examiner's conclusions were of "questionable probative value" when the examiner failed to consider certain relevant information. Mariano v. Principi, 17, Vet. App. 305, 312 (2003). A medical opinion must support its conclusions with analysis. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). "Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions [without reasoning or rationale]." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Therefore, the April 2007 VA examiner's opinion here is threadbare, thus entitling it to only limited probative value. With regard to the evidence against aggravation beyond normal progression, in February 2005 an Air Force Physical Evaluation Board (PEB) determined that the Veteran's cervical spine degenerative disc disease was not ratable at that time. Given the objective evidence of cervical spine pain and pathology from 2003 to 2005, the Board is highly skeptical as to the validity of this finding. With regard to the evidence in support of aggravation beyond normal progression, the STRs dated in 2003 and 2004 repeatedly document treatment, complaints and evaluations for the Veteran's cervical spine degenerative disc disease. She underwent physical therapy and steroid injections to quell the chronic pain. There are numerous notations regarding "worsening" and "increasing" cervical spine pain. She was placed on pain medication. The pain was described as "chronic" and "recurrent." With regard to the evidence in support of aggravation beyond normal progression, post-service VA, SSA, and military clinic records dated from 2005 to 2013 continued to document treatment for the cervical spine degenerative disc disease. With regard to the evidence in support of aggravation beyond normal progression, in a March 2004 AF Form 348, Line of Duty Determination, the Air Force Chief of Aerospace Medicine, after reviewing the Veteran's history of cervical spine treatment, opined that her underlying condition likely existed prior to service, but "current symptoms [might] well have been aggravated by service." With regard to the evidence in support of aggravation beyond normal progression, a March 2005 Air Force Medical Board Report assessed that cervical spine degenerative disc disease existed prior to service, and was "permanently aggravated by service." No basis for this finding was provided. In any event, overall, in the light of this evidence during and after the Veteran's final period of service in 2003 and 2004, the Board cannot show by clear and unmistakable evidence that the Veteran's cervical spine degenerative disc disease was not aggravated by her service, for purposes of rebutting the presumption of soundness at entry. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). See also Wagner, supra; VAOPGCPREC 3-2003. In this regard, clear and unmistakable evidence is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). A finding of "insufficient evidence" of aggravation does not meet VA's burden, only affirmative evidence proving that there was no aggravation does. Horn v. Shinseki, 25 Vet. App. 231 (2012). This burden has not been met, as probative medical evidence of record exists of in-service aggravation of the preexisting cervical spine degenerative disc disease. In other words, here, there is affirmative evidence of no aggravation. As noted, when no preexisting condition is noted upon entry into service, if the government fails to rebut the presumption of soundness under Section 1111 by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service, the Veteran's claim is one of service connection by direct in-service incurrence. Wagner, 370 F.3d at 1096. The presumption of soundness would apply, even when there was evidence of a preexisting condition, if the VA fails to show by clear and unmistakable evidence that a preexisting condition was not aggravated by service. Id. This essentially has the effect of converting an aggravation claim into one for service-connected disability where the government could not show a lack of aggravation of a preexisting condition by clear and unmistakable evidence. Id. This means that no deduction for the degree of disability at the time of entrance will be made if a rating is awarded, even though the case is technically being awarded based on evidence of aggravation of a preexisting disorder. Id. On this point, the Court recently reemphasized that once the presumption of soundness is applied, if the VA is unable to rebut the presumption, the disease or injury that manifested in service is deemed incurred in service, such that the second element of service connection is established. At that point, however, a Veteran still must establish that he has a current disability that is related to the in-service injury or disease. This nexus determination is based on a weighing of the evidence by the preponderance of the evidence standard, with the benefit of the doubt given to the Veteran. Gilbert v. Shinseki, 26 Vet. App. 48, 52 (2013). "It does not necessarily follow . . . that an unrebutted presumption of soundness will lead to service connection for the disease or injury. The appellant must still demonstrate a current disability and a nexus between his current disability and the injury or disease in service. Horn v. Shinseki, 25 Vet. App. 231, 236-37 (2012). See also Holton v. Shinseki 557 F.3d 1362, 1367 (Fed. Cir. 2009); Dye v. Mansfield, 504 F.3d 1289, 1292-93 (Fed. Cir. 2007) (affirming the Court's finding that the presumption of soundness does not eliminate the need to demonstrate a causal connection between a Veteran's current condition and his in-service injury)." With regard to in-service incurrence, the STRs dated from January 2003 to August 2004 document a chronic disability, cervical spine degenerative disc disease and arthritis. Post-service, VA, SSA, and military clinic records continue to document treatment for the same chronic cervical spine degenerative disc disease and arthritis. The Federal Circuit recently held that the regulation creating a presumption of service connection for "chronic diseases" manifesting during service and then again at any later date (38 C.F.R. § 3.303(b)), is only available to establish service connection for the "chronic diseases" enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). As relevant to the current appeal, this list of "chronic diseases" includes arthritis. See 38 C.F.R. § 3.309(a). Moreover, under the plain language of § 3.303(b), the Federal Circuit has previously held that there is a presumption of service connection for a chronic disease (rebuttable only by "clearly attributable intercurrent causes"), which manifests during service and then again "at any later date, however remote." Groves v. Peake, 524 F.3d 1306, 1309 (2008). The medical nexus evidence is not required to establish service connection if the evidence, regardless of its date, shows that a Veteran had a chronic condition in service, and that he still has the same chronic condition. Id. at 1309-1310. Accordingly, giving the Veteran the benefit of the doubt, service connection for cervical spine degenerative disc disease and arthritis is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Governing Laws and Regulations for Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of her disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). VA regulation indicates that the Veteran's entire history is reviewed when assigning a disability evaluation per 38 C.F.R. § 4.1. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R.§ 3.159(a)(2). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Analysis - Increased Rating Above 30 Percent In the June 2007 rating decision on appeal, the RO granted service connection for a major depressive disorder. The service-connected major depressive disorder is rated under Diagnostic Code 9434. 38 C.F.R. § 4.130. Because the Veteran has perfected an appeal as to the assignment of an initial rating following the initial award of service connection for major depressive disorder, the Board is required to evaluate all the evidence of record reflecting the period of time between the effective date of the initial grant of service connection until the present. The Board will also consider probative evidence prior to this date, to the extent this evidence sheds additional light on the Veteran's overall disability picture. This has resulted in "staged ratings" based upon the facts found during the period in question. Fenderson v. West, 12 Vet. App. 119, 126 (1999). That is to say, the Board must consider whether there have been times when her major depressive disorder has been more severe than at others. Id. In the present case, from October 20, 2006 to May 19, 2008, the Veteran's service-connected major depressive disorder is rated as 30 percent disabling. Beginning on May 19, 2008, the service-connected major depressive disorder is rated as 70 percent disabling. The Veteran contends that her service-connected major depressive disorder is more severe than is contemplated by the currently-assigned 30 and 70 percent ratings. Mental disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Once a Veteran has been diagnosed with a service-connected mental disorder, the VA reviews her medical history to determine how badly the disorder has disrupted the Veteran's social and occupational functioning. The level of disability is rated according to a General Rating Formula for Mental Disorders, codified at 38 C.F.R. § 4.130 ("General Rating Formula"), which provides for ratings of zero, 10, 30, 50, 70, or 100 percent. The VA compensates veterans beginning at 10 percent disability, and compensation increases at each level. As provided by the General Rating Formula, a 30 percent disability rating is appropriate when there is 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). 38 C.F.R. § 4.130. A 50 percent rating is appropriate when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is in order when there is 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 inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is 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; and memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Federal Circuit recently clarified that the General Rating Formula for Mental Disorders requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency or duration; but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). In evaluating the evidence, the Board has also noted various GAF scores contained in the DSM-IV, which clinicians have assigned. A GAF score 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, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. Higher GAF scores denote increased overall functioning of the individual. For instance, a score of 21-30 illustrates "[b]ehavior . . . 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)." DSM-IV at 46-47. A score of 31-40 represents "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) 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 is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school)." Id. A score of 41-50 illustrates "[s]erious 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)." Id. A higher score of 51-60 represents "[m]oderate 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)." Id. A higher score of 61-70 illustrates "[s]ome 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." Id. Prior to May 19, 2008, the evidence of record is consistent with a higher initial 50 percent rating for the service-connected major depressive disorder. 38 C.F.R. § 4.7. Certain reported signs and symptoms are indicative of the 50 percent rating criteria. See 38 C.F.R. § 4.130. The Board has also considered additional, similar symptomatology not specifically addressed in the 50 percent criteria under the General Rating Formula. See again Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In making this determination, the Board has reviewed VA mental health treatment (outpatient and inpatient) records dated from 2006 to 2008; a December 2006 National Guard Temporary Disability Retirement List (TDRL) evaluation; post-service military clinic records dated from 2004 to 2006; a VA psychological examination dated in April 2007; SSA disability records dated from 2006 to 2008; hearing testimony; representative argument, and lay statements from the Veteran. Prior to May 19, 2008, this medical and lay evidence of record documents such signs and symptoms including frequent depression and anxiety, anger and irritability, social isolation, "anxious" or "constricted" or "flat" or "tense" affect, slowed speech, low confidence, decreased interest, decreased energy, panic attacks (at times more than once a week), poor concentration, low frustration tolerance, crying spells, chronic sleep impairment, forgetfulness with tasks, and short and long term memory impairment (at times), and psychiatric symptomatology often described as "moderate." The Veteran has also described using alcohol to self medicate her psychiatric symptoms. The Veteran took several psychiatric medications for her major depressive disorder. She also received individual and group psychotherapy. Overall, consideration of these symptoms and circumstances reflects occupational and social impairment with reduced reliability and productivity, indicative of a 50 percent rating. See 38 C.F.R. § 4.130. In fact, the April 2007 VA psychological examiner specifically found that her psychiatric symptoms caused occupational and social impairment with reduced reliability and productivity. Another important factor is that many, but not all of the GAF scores in these records are indicative of "moderate" impairment. See October 2004 military clinic record (GAF scores of 51-60); December 2006 TDRL evaluation (GAF scores of 50-55); February 2006 and March 2007 VA psychology consults (GAF score of 65); April 2007 VA psychological examination (GAF score of 55); November 2007 VA psychiatry assessment (GAF score of 70). Although the VA examiner's use of this descriptive term is not dispositive of the rating that should be assigned, it is nonetheless probative evidence to assist in making this important determination. 38 C.F.R. §§ 4.2, 4.6. With regard to work, the Veteran has not been gainfully employed since her discharge from service in August 2004. Her psychiatric issues cause memory loss for tasks and concentration problems. She is overwhelmed with anxiety very easily, and has poor frustration tolerance. However, SSA disability records also document the effects of her service-connected cervical spine degenerative disc disease on her ability to work. In any event, the Veteran at the very least has difficulty in establishing and maintaining effective work and social relationships with reduced reliability and productivity, an important criterion for a 50 percent rating. Accordingly, on this record, prior to May 19, 2008, the service-connected disability picture is found to more nearly resemble the criteria warranting an increased initial 50 percent rating for the service-connected major depressive disorder. 38 C.F.R. § 4.3. Any minor fluctuations in the severity of her disability were episodic or temporary in nature. However, prior to May 19, 2008, the evidence of record does not warrant a 70 percent rating for the service-connected major depressive disorder. 38 C.F.R. § 4.7. The medical and lay evidence of record is not indicative of someone with psychiatric symptomatology causing occupational and social impairment with deficiencies in most areas, required for the higher 70 percent rating. 38 C.F.R. § 4.130. Initially, her GAF scores are not indicative of "serious" or "severe" impairment, providing evidence against a higher rating. Prior to May 19, 2008, the probative medical and lay evidence of record has repeatedly noted no suicidal ideation; no obsessional rituals which interfere with routine activities; no speech intermittently illogical, obscure, or irrelevant; no near-continuous panic; no spatial disorientation (Veteran was always oriented to person, place, and situation); no neglect of personal appearance and hygiene; and no inability in establishing and maintaining effective relationships. She was deemed capable of managing her VA benefits. The Veteran was still able to maintain relationships with her family members, upon whom she often relied. She was divorced and had a daughter. She occasionally dated. She had few friends. She cooked and cleaned but was generally alone most of the time. She had some impairment in basic activities of daily living. The Board acknowledges that, prior to May 19, 2008, a few severe symptoms were mentioned. There was one instance of suicide ideation (August 2004 military clinic note), some evidence of impaired impulse control with irritability, occasional neglect of personal appearance, and some evidence the Veteran had difficulty in adapting to stressful circumstances at work. Nevertheless, even when considering the few instances of these symptoms, prior to May 19, 2008, the Veteran's symptoms did not cause occupational and social impairment with deficiencies in most areas, to which a 70 percent disability requirement refers. See Vazquez-Claudio, 713 F.3d at 118 (the Veteran's psychiatric symptoms must cause the level of occupational and social impairment specified in the General Rating Formula). The evidence of record discussed in detail weighs more heavily against a 70 percent rating for this initial period of the appeal. Overall, prior to May 19, 2008, the Veteran's level of occupational and social impairment is more than adequately reflected in the 50 percent rating currently assigned. 38 C.F.R. § 4.10. Analysis - Increased Rating Above 70 Percent Beginning on May 19, 2008, the service-connected major depressive disorder is rated as 70 percent disabling. This 70 percent rating was based on a May 19, 2008 private facility admission (contained in SSA disability records) documenting voluntary hospitalization by the Veteran for her depression, bipolar disorder, and alcohol abuse at that time. She was briefly assigned a GAF score of 30 upon admission. Subsequent GAF scores throughout the appeal were higher. Beginning on May 19, 2008, the evidence of record does not warrant a higher initial 100 percent rating for the service-connected major depressive disorder. 38 C.F.R. § 4.7. The medical and lay evidence of record is not indicative of total occupational and social impairment, which is required for a 100 percent rating. 38 C.F.R. § 4.130. Overall, the Veteran's reported signs and symptoms are more indicative of the 70 percent rating criteria. See 38 C.F.R. § 4.130. In making this determination, the Board has reviewed VA mental health treatment (outpatient and inpatient) records dated from 2008 to 2013; VA psychological examinations dated in August 2009 and December 2011; SSA disability records dated from in 2008 and 2009; hearing testimony; representative argument, and lay statements from the Veteran. This medical and lay evidence of record documents such signs and symptoms indicative of a 70 percent rating including near-continuous panic or depression, anxiety, mood swings, frequent panic attacks, some suicidal thoughts, evidence of losing consciousness due to alcohol use, impaired impulse control, irritability, neglect of personal hygiene and appearance at times, difficulty in adapting to stressful circumstances, memory impairment, difficulty concentrating, and social impairment. The Veteran had several instances of inpatient psychiatric treatment, including a VA Psychosocial Residential Rehabilitation Treatment Program (PRRTP). VA also judged the Veteran as incompetent for purposes of managing VA payments. See September 2008 SSA psychiatric report; January 2010 rating decision. Her symptoms were described as "moderate to severe." See June 2008 VA psychiatry medication note. The Veteran has also described using alcohol to self-medicate her psychiatric symptoms. The Veteran takes several psychiatric medications for her major depressive disorder. She also received individual and group psychotherapy. However, the medical and lay evidence of record also shows no gross impairment in thought processes or communication; only very limited instances of delusions or hallucinations (not persistent), no grossly inappropriate behavior; no "persistent" danger of hurting self; no disorientation to time or place (with one exception); and no memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130. There is no probative evidence of total occupational and social impairment due to these factors. In fact, both the August 2009 and December 2011 VA psychological examinations found that the Veteran's level of psychiatric symptoms did not cause total occupational and social impairment. The December 2011 VA examiner found that the Veteran was once again competent to manage her affairs. As to work impairment, the Veteran has not been gainfully employed since her discharge from service in August 2004. Her psychiatric issues cause memory loss for tasks and concentration problems. She is overwhelmed with anxiety very easily, and has poor frustration tolerance. However, SSA disability records also document the effects of her service-connected cervical spine degenerative disc disease on her ability to work. The December 2011 VA examiner assessed that the Veteran was not precluded from work due to her service-connected psychiatric disability. There was only "some reduced productivity in the work environment" due to difficulty concentrating and low energy. The SSA determined that the Veteran was disabled since 2005 when considering the combination of her psychiatric and physical impairments (cervical disc disease). As to social impairment, the Veteran indicates that she is able to volunteer 10-20 hours a week. See December 2011 VA examination. This is not representative of total social impairment. She lives with family members, requires supervision, and maintains a relationship with them, although she is isolated and distant. Nonetheless, she can still function and communicate with people, albeit with significant limitations. She does exhibit social withdrawal, with a rather isolated lifestyle. She exhibits poor judgment. Social and public interaction is difficult for the Veteran. At times, the Veteran's hearing testimony supports this conclusion as well. See February 2013 hearing testimony at page 15. But while socially isolated, she can still participate in individual and group psychotherapy. Her GAF scores, with one or two exceptions during inpatient treatment, are also not reflective of total occupational and social impairment. See May 19, 2008 private facility admission (contained in SSA disability records) (GAF score of 30); May 2008 VA inpatient discharge report (GAF scores of 40 and 50); June 2008 VA psych note (GAF score of 60); July 2008 VA inpatient note (GAF score of 50); August 2009 VA examination (GAF score of 60); August 2010 VA psych note (GAF scores of 21-30); November 2010 VA psych notes (GAF score of 45 and 55-60); December 2010 VA psych notes (GAF scores of 60-65 and 65-70); July 2011 VA psych note (GAF score of 55); August 2011 VA psych note (GAF score of 49); September 2011 VA psych note (GAF score of 61); December 2011 VA psych note (GAF score of 47); and December 2011 VA examination (GAF score of 60). Although the VA examiner's use of this descriptive term is not dispositive of the rating that should be assigned, it is nonetheless probative evidence to assist in making this important determination. 38 C.F.R. §§ 4.2, 4.6. The Board acknowledges that, as of May 19, 2008, the Veteran at times exhibited a few of the symptoms listed under the 100 percent rating criteria. At times there was an intermittent inability to perform activities of daily living or to maintain personal hygiene; on a few occasions the Veteran was not oriented to time or place; there were several instances of auditory and visual hallucinations. See e.g., April 2009 SSA psychological examination. However, most treatment records after May 19, 2008 are negative for this symptomatology. In addition, generally, the Veteran is capable of completing simple tasks on a regular basis - see June 2009 SSA functional capacity report. Overall, even when considering the few instances, as of May 19, 2008, the Veteran's symptoms do not cause total occupational and social impairment, to which a 100 percent disability requirement refers. See Vazquez-Claudio, 713 F.3d at 118 (the Veteran's psychiatric symptoms must cause the level of occupational and social impairment specified in the General Rating Formula). The evidence of record as discussed weighs more heavily against a 100 percent rating. Thus, as of May 19, 2008, the Veteran's level of occupational and social impairment is more than adequately reflected in the 70 percent rating currently assigned. 38 C.F.R. § 4.10. Accordingly, as of May 19, 2008, the Board finds that the evidence is against an initial disability rating greater than 70 percent for the service-connected major depressive disorder. 38 C.F.R. § 4.3. Fenderson Consideration The 50 and 70 percent ratings for the Veteran's major depressive disorder the Board has assigned should be effective prior to and after May 19, 2008, respectively. Since the effective date of her awards, the service-connected major depressive disorder has never been more severe than contemplated by its 50 and 70 percent ratings, so the Board cannot "stage" her ratings any further. Fenderson, 12 Vet. App. at 126. Extraschedular Consideration Finally, there is no evidence of exceptional or unusual circumstances to warrant referring the case for extraschedular consideration. 38 C.F.R. § 3.321(b)(1). The General Rating Formula for Mental Disorders reasonably describes the Veteran's disability level and symptomatology with contemplation of the relative degree of occupational and social impairment. The Board finds that the Veteran's psychiatric symptomatology is fully addressed by the rating criteria under which such disability is rated. Therefore, since the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008); VAOPGCPREC 6-96. In other words, since the Veteran's disability picture is contemplated by the Rating Schedule, there is no exceptional disability picture that would warrant consideration of factors such as marked interference with employment or frequent periods of hospitalization. Thun, 22 Vet. App. at 116. See also 38 C.F.R. § 3.321(b)(1). The medical and lay evidence of record fails to show anything unique or unusual about the Veteran's major depressive disorder that would render the schedular criteria inadequate. All of the Veteran's psychiatric symptoms are contemplated in the 50 and 70 percent rating assigned, including her degree of work and social impairment. Moreover, the Veteran also has never argued for an extraschedular rating under § 3.321(b). ORDER Service connection for cervical spine degenerative disc disease and arthritis is granted. Prior to May 19, 2008, an increased, initial 50 percent disability rating, but no higher, for the service-connected major depressive disorder is granted, subject to the regulations controlling disbursement of VA monetary benefits. Beginning on May 19, 2008, an increased, initial disability rating greater than 70 percent for the service-connected major depressive disorder is denied. REMAND With regard to the claim for a TDIU rating, in this decision, the Board has granted service connection for cervical spine degenerative disc disease and arthritis. The Board has also granted an increased initial rating of 50 percent for major depressive disorder prior to May 19, 2008. As a result, this case must be returned to the RO for the assignment of disability ratings and effective dates for each of these service-connected disabilities. Subsequently, the RO must then reconsider the TDIU issue, which is inextricably intertwined with assignment of percentage ratings and effective dates for the service connection and increased rating awards. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, the remaining claim for a TDIU rating is REMANDED for the following action: After assigning initial disability ratings and effective dates for the service-connected cervical spine degenerative disc disease and major depressive disorder, and completing any other required development, the RO should readjudicate the claim for a TDIU rating in light of all the evidence of record. (The RO should determine if the Veteran meets the percentage requirements for TDIU rating under 38 C.F.R. § 4.16(a)). If any benefit sought on appeal remains denied, the RO should furnish a fully responsive SSOC to the Veteran and her representative and they should be afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs