Citation Nr: 1320851 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 07-36 323 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to a disability rating in excess of 50 percent for service-connected schizophrenia, paranoid type, prior to February 10, 2011, and in excess of 70 percent thereafter. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran served on active duty from October 1968 to June 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal of a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York, which continued the 50 percent rating for the Veteran's service-connected schizophrenia, paranoid type. The Veteran appeared and testified at a Board hearing held at the RO before a Veterans Law Judge in June 2009. A copy of the transcript of this hearing has been associated with the claims file. A review of the transcript demonstrates that the Veterans Law Judge complied with the requirements set forth in Bryant v. Shinseki, 23 Vet. App. 488, 491-93 (2010). In September 2009, the Board issued a decision that denied the Veteran's claim for an increased rating for schizophrenia, paranoid type. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In May 2010, the Court vacated the Board's decision and remanded the case for readjudication in compliance with a May 2010 Joint Motion for Remand. In a December 2010 letter from the Board, the Veteran was notified that the Judge who conducted his June 2009 Travel Board hearing was no longer employed by the Board and advised him of the opportunity to provide testimony before a current member of the Board. He was also advised that he was to respond within 30 days if he wanted another hearing and that if no response were received within the prescribed time period, the Board would assume that he did not want another hearing. The Veteran has indicated that he does not desire another hearing. In January 2011, the Board remanded the Veteran's claim for additional development. The Board finds that substantial compliance with its remand directives was accomplished. By rating decision issued in January 2012, a disability rating of 70 percent for the Veteran's service-connected schizophrenia, paranoid type, was awarded effective February 10, 2011; however, a disability rating higher than 50 percent prior to then remained denied. In March 2013, the Veteran's claim was again before the Board. The new evidence since the last remand indicated that the Veteran was seeking Social Security Administration disability compensation. Consequently, the Veteran's claim was remanded to obtain his Social Security Administration records. Such development was accomplished and the Veteran's claim has been returned to the Board. The Board finds that it is ready for final adjudication. FINDINGS OF FACT 1. Resolving all reasonable doubt in his favor, during the period prior to February 10, 2011, as well as after, the Veteran's disability picture for his service-connected schizophrenia, paranoid type, more nearly approximates occupational and social impairment with deficiencies in most areas. 2. 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, has not been shown at any time. CONCLUSION OF LAW The criteria for a disability rating of 70 percent, but no higher, for service-connected schizophrenia, paranoid type, are met. 38 U.S.C.A. §§ 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7 and 4.130, Diagnostic Code 9403 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance Requirements VA's duties to notify and assist claimants in substantiating a claim for VA benefits are described in 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and notify the claimant and his or her representative, if any, of what information and evidence not already provided, if any, is necessary to substantiate, or will assist in substantiating, each of the five elements of the claim including notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Sufficient notice must inform the claimant (1) of any information and evidence not of record that is necessary to substantiate the claim; (2) of the information and evidence that VA will seek to provide; and (3) of the information and evidence that the claimant is expected to provide. Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). For a claim seeking increased compensation for an already service-connected disability, 38 U.S.C.A. § 5103(a) requires, at a minimum, that VA notify the claimant that he/she must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment in order to substantiate the claim. Vazquez-Flores, 22 Vet. App. 37 (2008). VA must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation. Id. It is noted that, on September 4, 2009, the Federal Circuit vacated and remanded Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), and Schultz v. Peake, No. 03-1235, 2008 WL 2129773, at 5 (Vet. App. Mar. 7, 2008). Specifically, the Federal Circuit concluded that "the notice described in 38 U.S.C. § 5103(a) need not be veteran specific." In addition, the Federal Circuit determined that "while a veteran's 'daily life' evidence might in some cases lead to evidence of impairment in earning capacity, the statutory scheme does not require such evidence for proper claim adjudication." Thus, the Federal Circuit held, "insofar as the notice described by the Veterans Court in Vazquez-Flores requires the VA to notify a veteran of alternative diagnostic codes or potential 'daily life' evidence, we vacate the judgments." In this case, notice was sent to the Veteran in October 2006, prior to the initial adjudication of his claim. Additional notice was provided in May 2007. In these notices, he was advised of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. Finally, he was advised that should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. Id., see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). He was also advised of what evidence and/or information is necessary to establish entitlement to an effective date should benefits be granted. The Board acknowledges that the notice letters sent to the Veteran do not fully meet the requirements set forth in Vazquez-Flores and are not sufficient as to content and timing. However, content-compliant notice was provided to the Veteran in June 2008, and his claim was subsequently adjudicated in July 2008 and June 2009. Thus, the Board finds that any deficiency as to timing has been cured. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (defects in timing of notice may be cured by affording the Veteran appropriate notice and subsequent adjudication). The Board may therefore proceed to adjudicate the Veteran's claim without prejudice to him. With respect to VA's duty to assist, VA is only required to make reasonable efforts to obtain relevant records that the Veteran has adequately identified to VA. 38 U.S.C.A. § 5103A(b)(1). All efforts have been made to obtain relevant, identified and available evidence. Neither the Veteran nor his representative has identified any evidence that has not been obtained that is relevant to his claim. The duty to assist includes providing the Veteran a thorough and contemporaneous examination. Green v. Derwinski, 1 Vet. App. 121 (1991). The Veteran was afforded VA examinations in November 2006, September 2007, May 2009, February 2011 and July 2012. Significantly, the Board observes that he does not report that the condition has worsened since he was last examined, and thus a remand is not required solely due to the passage of time. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Furthermore, the Board finds that the reports of these examinations reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate physical examinations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2009); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran. Additional efforts to assist or notify him would serve no useful purpose. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2. It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor, 38 C.F.R. § 4.3. 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. While the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected schizophrenia, paranoid type, is currently evaluated under Diagnostic Code 9203. The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. 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. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. at 443. The current 50 percent disability rating requires a showing of: 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. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. And, the criteria for a 100 percent rating are: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent 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. 38 C.F.R. § 4.130. A Global Assessment of Functioning (GAF) score represents the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness," and is also important in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). A GAF score of 21 to 30 denotes behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home or friends). A GAF score of 31 to 40 denotes some 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). A GAF score of 41 to 50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 denotes moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 denotes 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. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, pg. 47 (4th ed., revised 1994) (DSM-IV). The Board notes that the Veteran filed his claim for an increased disability rating in September 2006; hence, the Board should look back to the year prior to the submission of his claim to see if there is evidence of an increase in severity of the Veteran's service-connected disability. See 38 C.F.R. § 3.400(o)(2). An October 2005 VA psychiatric treatment note indicates that the Veteran initiated mental health treatment with a VA medical facility for the first time since 1980. He complained of "feeling bad for many years." The clinician noted that while the Veteran had difficulty verbalizing his symptoms, his main problem appeared to be depression. He also complained of sleep disturbances. The Veteran reported "a problem getting along with people" but could not elaborate on this statement. He denied any psychotic symptoms. The Veteran reported having held various jobs since service but that he had been working for the same company for 12 years. He reported that he did not have a good relationship with anyone at work as he felt they did not like him; however, he did not report any overt paranoia or suspiciousness. He had been married for 26 years and reported limited involvement with his children and no contact with his mother and siblings. The clinician noted that the Veteran was uncomfortable during the interview, and he was rather vague in his responses to questions and could not give a complete and coherent history or full description of symptoms. He reported his mood was low and he felt hopeless. His affect was blunted. His speech was monotonous and sparse. He denied auditory or visual hallucinations and did not verbalize any overt delusions. He had a paucity of thoughts to include some thought blocking. Some looseness of associations was present. He denied any suicidal or homicidal ideations. Insight and judgment were limited. The clinician diagnosed depressive disorder, not otherwise specified, and psychosis, not otherwise specified. He also indicated that schizophrenia undifferentiated and schizoaffective disorder should be ruled out. The clinician assigned a GAF score of 55 and prescribed Zoloft. Subsequent psychiatric treatment notes indicate the Veteran was doing better with his medications, but he continued to have intermittent paranoia, especially with regard to his coworkers, and not feeling comfortable with other people as he doubted their intentions and misinterpreted their words and actions. He had occasional altercations at work as evidenced in a February 2006 psychiatric treatment note. He, however, continued to work full time. A GAF score of 55 was continued until July 2006. At this time, the Veteran was seen and was not able to report on whether the change in his medications last time from Respiridone to Abilify increased control of his irritability and suspiciousness. Some thought blocking was noted but his mood and anxiety were reported as okay. A GAF score of 53 was assigned. He continued to remain quite paranoid at work, misinterpreting people's statements; getting into arguments; and feeling like people are talking about him, etc. (See August 2006 psychiatric treatment note.) In October 2006, he finally reported some improvement with the last increase in the dosage of Abilify but admitted his mood was low and he felt anxious. Thus, his antidepressant was changed to Paxil. On November 2, 2006, the Veteran was seen for his regular psychiatric follow up. He reported things did not go well with the change to Paxil and, thus, he discontinued all of his medications. He was very suspicious, especially at work, and had difficulty getting along with coworkers. He further reported that he now has another employee working with him directly and this was a problem as he did not like to be in such close contact with people. He was still very easily agitated, irritable, with low frustration tolerance and poor impulse control. He denied hallucinations and suicidal or homicidal ideations. His main issues were paranoia and mistrust. His mood was low. He did seem to have some thought blocking. A VA mental disorders examination was conducted on November 7, 2006 . The Veteran was accompanied by his wife, who drove him to the appointment. The examiner noted the Veteran's prior history of hospitalizations and treatment, and that he was diagnosed to have paranoid schizophrenia and related depression. The Veteran reported that his medications resulted in rather in negative side effects and currently he was not taking any medications. On examination, the Veteran was cooperative with the interview; however, his eye contact was marginally adequate. His speech was noticeably stiff, monotone, and lacking in spontaneity; it was otherwise somewhat underproductive but grossly relevant and coherent. His thought processes were rational and goal directed. There was no evidence of hallucinations or delusions. However, he did present with recurrent evidence of thought blocking. At one point, the Veteran acknowledged that "sometimes I can't think." This seems to be when he feels stressed such as even during this examination. There was no evidence of specific obsessions, compulsions, phobias, or ritualistic behaviors. He was oriented times three. Although he did well on simple tests for short-term memory and concentration, he reported problems focusing on more complex tasks as his paranoid thoughts or thought blocking will interfere with this. His mood seemed quite anxious. His affect was blunted in a manner typical with an individual with a chronic schizophrenic disorder. The examiner stated that the results of the current evaluation were consistent with a diagnosis of a chronic paranoid schizophrenia. He was currently experiencing recurring paranoid ideation although his paranoid thoughts at that point were not bizarrely delusional. Instead, the Veteran reported recurring problems with suspiciousness and mistrust of his coworkers at work as he felt that they were constantly trying to "do me in" or do him some type of harm or damage. The examiner stated that it is quite possible that, at this point, due to his complaints or concerns, his coworkers may actually be retaliating somewhat or certainly talking about him, which may accentuate his mistrust and paranoia. He also reported that at times he even feels mistrust of his wife in that he is afraid she is talking to others about him. The examiner further noted there is evidence of recurring thought blocking which, when it occurs, makes it difficult for the Veteran to process information and react to his environment. There was also evidence of negative schizophrenic symptoms including moderate symptoms of passivity, negativity and inertia. He presented with decreased motivation and energy level, recurring low mood states, decreased self-esteem, social withdrawal, social anxiety, and general distress symptoms. He was not currently suicidal or homicidal. His insight and judgment were generally good. The diagnosis was schizophrenia, paranoid, chronic, moderate to severe. The examiner assigned a GAF score of 49. In discussing the Veteran's functional assessment, the examiner noted that the Veteran had difficulty with any activity that required dealing with the public or any type of social situation, which results in an exacerbation and flare up of his mistrust, suspiciousness and paranoia. He becomes markedly uncomfortable, anxious and irritable in these situations, and avoids them when he can. The examiner stated that the Veteran's ability to function in these situations is quite impaired. Thus, the examiner concluded that the Veteran's current level of personal and social adjustment is moderately to severely impaired. He stated that the Veteran's capacity to relate to others in a stable and calm manner was limited as he does tend to be quite suspicious and paranoid of others. Furthermore, he also experienced recurring depression, which the examiner noted is a common symptom particularly for more chronic schizophrenia along with typical negative symptoms such as passivity and inertia. The Veteran's ability to enjoy activities was limited. His sleep was also impaired. The examiner opined that the Veteran's quality of life was "disrupted to a significant degree," particularly in terms of his interpersonal functioning. The examiner further stated that the Veteran was presenting with ongoing and moderate problems regarding his level of occupational functioning. He wrote that "[w]hile [the Veteran] is able to maintain himself at work, he is doing so just barely and with some significant problems." His paranoia was clearly being expressed at work and it likely did stir things up with his coworkers and bosses. He presented as quite uncomfortable at work in terms of his ability to relate to others; and he preferred to be just left alone at work. The examiner stated that the Veteran will continue to have some difficulty at work unless, hopefully, a medication can be found that he can tolerate that can reduce his paranoia. On November 14, 2006, the Veteran was seen in VA Mental Health as a walk-in. He reported having to take time off from work as he was not doing well. He reported he had been very anxious, very paranoid, could not get comfortable, could not interact appropriately with people especially at work as he is suspicious of everyone. He reported not sleeping at night and not being able to rest. He was angry, frustrated and tired. He was very paranoid and was also evidencing thought blocking and was having difficulty conveying his thoughts. He was prescribed Quetiapine and Ambien. A GAF score of 45 was assigned. The Veteran was seen again as a walk-in three days later. He had vague complaints of various side effects from the medications. He reported still not sleeping at night, feeling dizzy, unsteady and groggy. He was still very anxious and stated he had been experiencing palpitations, sweating and shortness of breath. Ambien was discontinued and he was started on Xanax for his anxiety. A GAF score of 45 was continued. He was seen for follow up on November 21st, at which time he reported that the Quetiapine had made him more anxious and unable to sit still. The clinician noted that it appeared that this medication had caused akathesia, which in turn increased his level of anxiety. The Quetiapine was discontinued, and the Veteran was prescribed Geodon. A GAF score of 45 was continued. At follow up on November 28th, the Veteran reported finding the Geodon very helpful. He was now sleeping better and night. He was also able to go to work and better able to function at work. The clinician noted that Veteran was still anxious but not as much as in the past. He was also still paranoid but not agitated. Finally, he was still having thought blocking. A GAF score of 45 was continued. Although subsequent treatment notes show the Veteran improved on these medications, GAF scores of only 47, 48 and 50 were assigned in December 2006, January 2007 and May 2007, respectively. Also, the January 2007 treatment note indicates the Veteran reported thinking of death often, but not suicide. The clinician prescribed Wellbutrin for depression. In July 2007, the Veteran had improved such that his clinician assigned a GAF score of 55. At that time, the Veteran reported things were going well. His mood was neutral, and his affect was constricted but appropriate. He was doing better at work and getting along with his family. The Veteran reported some paranoia but indicated that he was able to manage it. The Veteran underwent a second VA mental disorders examination in September 2007. He was accompanied again by his wife. The Veteran reported a positive marital relationship. He continued to have paranoid ideation at work, but indicated that "for the most part" his job performance was adequate. He complained of a sleep impairment and distress episodes. He reported episodes of suicidal ideation; however, the examiner noted that he thoroughly examined the Veteran for any suicidal risk, and at this time found none. The Veteran's speech was generally relevant and coherent. His thought processes were rational and goal directed. There was no evidence of hallucinations, delusions, or ritualistic behaviors. His short-term memory and concentration skills were intact. However, the Veteran reported recurring disruptions in his focus and concentration that the examiner felt were due to thought blocking and other schizophrenia related symptoms. His mood was subdued and his affect was flat. The examiner opined that there had been no significant change regarding the Veteran's symptoms compared to the November 2006 examination. In his opinion, the Veteran continued to present with symptoms best described as moderate to severe. His functional assessment of the Veteran was essentially the same. The examiner stated that the Veteran presented with schizophrenia related social anxiety and social avoidance, as well as negative schizophrenia symptoms. He continued to be quite uncomfortable in social situations or crowds, especially among strangers but sometimes also with family members. His preference was to be by himself or with just his wife and stepson. The examiner noted that there was no evidence that the Veteran's paranoid thinking disrupted the quality of his work; nevertheless, he does experience emotional distress at work due to his paranoid thinking. The examiner further noted that the Veteran continued to present with evidence of recurring thought blocking episodes, which makes it difficult at times for him to process information and react to his environment appropriately. There was also evidence of depressive symptoms such as recurring low mood, decreased self-esteem, decreased energy level and decreased motivation. The Veteran had sleep disturbance and decreased appetite. The examiner diagnosed schizophrenia, paranoid type, chronic, moderate to severe. He assigned a GAF score of 50. The examiner reiterated that, in his opinion, the Veteran had not experienced any change in the severity of his symptoms in one way or another since his last examination. Treatment records from October 2007 through April 2009 indicate that the Veteran was still working full-time. He essentially got along well with his wife, but had no other friends. He remained paranoid, especially at work. GAF scores during this time ranged from 50 to 55. The Veteran underwent another VA mental disorders examination in May 2009 by the same examiner who conducted the previous two VA examinations. This time he was unaccompanied. He reported an increase in his symptoms. The examiner noted that the Veteran's recent treatment notes indicated that he had maintained a relatively stable level of functioning "at what appears to be a moderate degree;" however, in his opinion, there was no evidence of any significant change in the Veteran's condition in that he continues to present with moderate to severe symptoms. He noted that, although the Veteran's symptoms may have achieved a somewhat high degree of stability, significant improvement was not noted. The Veteran continued to experience paranoid thoughts in reference to coworkers but he now reported also having them about his neighbors at times (thinking that they are talking about him or perhaps plotting against him). He continued to experience emotional distress at work because of his paranoid thoughts about his coworkers. He continued to present with recurring episodes of though blocking, significant social anxiety and social avoidance, negative schizophrenic symptoms and depressive symptoms. He reported occasional suicidal ideation; however, the examiner did not find evidence of any imminent suicidal or homicidal risk. He continued to present with a moderate sleep disturbance and decreased appetite. The examiner diagnosed schizophrenia, paranoid type, chronic, moderate to severe. The Board notes that there are two reports of this examination in the claims file and the only difference between them is that the first one gives a GAF score of 50 and the second one gives a GAF score of 57. At the June 2009 hearing, the Veteran testified that he has difficulty concentrating and has been having more problems at work. He reports thinking about suicide at least twice a week. He testified that he has daily panic attacks. He stated that he has no friends and does not go out with his wife. The Veteran stated that he was having problems with his memory. On February 2011, the Veteran underwent another VA examination. The examiner noted that the Veteran was fatigued and tense. His speech was slow with a two to three second delay in responding. His mood was anxious and his affect was blunted. He was easily distracted and had a short attention span. He reported that he did repetitious work and he had to stop frequently because he would lose track of what he was supposed to do. His thought process showed a paucity of ideas with paranoid ideation. He described having continued sleep impairment. There was no evidence of hallucinations, inappropriate behavior, or delusions. He did report some obsessive/ritualistic behavior in that he had to keep his tools in a particular order and, if someone changed them, he would get upset and may get angry and throw things. He also reported panic attacks in that he freezes and feels overwhelmed. There was no homicidal ideation; however, the Veteran reported having thoughts of wanting to kill himself with a plan of putting a plastic bag over his head. He reported doing very little at home because he is too tired after work to do anything. He also reporting having trouble being around more than one person at a time and tends to freeze if he is around people. He avoided shopping and recreational activities that took him outside the home. He stated the only thing he does for fun is watch television. He further reported increased stress over the prior few months because his wife's daughter and her three young children had been living with them, and the Veteran felt invaded. His remote and immediate memory were noted to be normal; however, his recent memory was moderately impaired. Occupationally, he reported continuing to work at his full time factory job. He reported poor social interaction with others. He stated he works on a job by himself and has problems if he has to interact with other people. He will get angry and will leave the floor a few times a week. He reported having come close to having a physical fight with a coworker but that the coworker backed off. The examiner's assessment was schizophrenia, paranoid type, chronic, moderate. She assigned a GAF score of 52. Despite indicating that the Veteran's mental disorder caused reduced reliability and productivity (i.e., the 50 percent criteria), the examiner further opined that the Veteran is increasingly disabled at work by his mental disorder and, in her estimate, he is 70 percent disabled at that time. Her rationale was that the Veteran was unable to tolerate interacting with other people and had episodes of anger a few times a week that prevent him from working for 10 to 20 minutes. His employers have been tolerant of his behavior, but in many job settings, his behavior would not be acceptable. Furthermore, the Veteran thinks and reacts slowly and could not do work where he had to respond to a variety of situations. Furthermore his recent memory impairment would likely make it difficult for him to do jobs at work and he may be drained by the effort to do what he is doing on the job. She stated that the Veteran is less and less able to function at home when he gets done with work because he is worn out from work. At some point, he is likely to be unable to tolerate full-time employment. VA psychiatric treatment records since April 2007 show the Veteran continued to have symptoms of paranoia, anxiety and irritability, as well as sleep disturbance. His GAF scores ranged from 50 to 55 until December 2011. The VA treatment records show that, in November 2011, the Veteran had a "stroke" (also diagnosed as a transient ischemic attack), which left him experiencing generalized weakness, slowing of speech and difficulty working. A December 2011 primary care treatment note indicates the Veteran stopped working and was applying for Social Security disability as a result of the residuals from his stroke. Subsequent VA psychiatric treatment records show GAF scores of 46 through 48; however, the Board finds that these scores reflect the residuals of the Veteran's nonservice-connected stroke. The Veteran underwent VA examination in July 2012. This examiner stated that the Veteran continues to display the symptoms of paranoid schizophrenia. The symptoms of this mental disorder do continue to severely impair his day to day functioning. He has no affect. He cannot relate to people. He is very suspicious of others intentions. He has persistent panic attacks. There are days when he has problems thinking and being confused. He has problems sleeping. The examiner opined that, even though the Veteran had a stroke in November 2011, his ability to engage in routine activities of daily living have been poor for years. He has suicidal thoughts. His hygiene is poor. He has no friends and rarely leaves the house. It was this examiner's professional opinion that, since the last examination, that the impairment to the Veteran's day to day functioning had not changed significantly. In summarizing the Veteran's occupational and social functioning, the examiner checked that he has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood (i.e., the criteria for a 70 percent rating). Finally, in a letter dated in May 2013, a VA psychiatrist stated that the psychiatrist had been treating the Veteran since October 2005. At that time, the Veteran was employed and took pride in working and earning a living and caring for his wife and children. While employed, he reportedly had struggled with paranoia (at times delusional in extent) a thought disorder, as well as negative symptoms such as blunted affect, paucity of thoughts and monotonous speech. He reportedly struggled to relate to and interact with his coworkers and supervisors. His coworkers sensed that he had psychiatric issues which caused them to be somewhat avoidant, and this heightened his paranoia leading to conflicts. In spite of this he continued to work until he suffered from a stroke in November 2011. Upon completing rehab, he returned to work, however, his memory and speech deficits further decreased his ability to interact with his coworkers. This led him to stop work in December 2011. The psychiatrist stated that given his current debilitated state, he felt that the Veteran could not deal with the day to day stressors of part time work, let alone full time work. The psychiatrist stated that if he had to return to work, the stressors of work would likely lead to paranoid delusions, thought disorder and depressed mood. He further stated that after the stroke, because of his psychotic disorder, he is not able to mobilize the coping skills required to return to a higher level of functioning. He presented in February with a GAF of 45 even without the stress of work. He is severely disabling. After considering the above evidence, the Board finds that the Veteran's disability picture is more consistent with the criteria for a 70 percent disability rating rather than a 50 percent rating. The medical evidence clearly demonstrates the Veteran has severe interpersonal impairment caused by his paranoia and suspiciousness. He has social anxiety and social avoidance. He feels uncomfortable around people, especially strangers. Because of these symptoms, he has not been able to establish any type of relationship with his coworkers. Furthermore, it is clear the Veteran has little to no friends or contact with family members outside of his wife and stepson. He even reported at times that he was suspicious of his wife and that this interfered with their relationship, although for the most part it appears that his marriage is fairly stable. He has reported avoiding going to crowded places such as stores and not participating in any recreational activities. The Board finds, therefore, that the Veteran's interpersonal impairment is most consistent with the 70 percent criterion of having an inability to establish and maintain effective relationships. The Board acknowledges that the Veteran appears to have a good relationship with his wife, but she is the only person he has indicated having any real relationship with. Otherwise, however, he is pretty much isolated from other people unless he is forced to be. Furthermore, the Board finds that the evidence demonstrates that the Veteran has difficult in adapting to stressful circumstances, especially at work. The medical evidence clearly shows that the Veteran has thought blocking. According to the VA examiner who conducted the first three examinations, when this occurs, it makes it difficult for the Veteran to process information and react to his environment, and that this worsens when the Veteran is under stress such as at the examination or when he is having increased symptoms. The Veteran has reported that this worsens when he experiences increased stress and that, during these times, he cannot think. The thought blocking also interrupts his focus and concentration making it more difficult for the Veteran to work efficiently. He has reported that his bosses had at times asked him to speed up complaining he is too slow. As for his occupational functioning, the Board notes that the Veteran was able to maintain his job working in a factory assembling vehicles for approximately 20 years; however, he quit after having a stroke in November 2011. Social Security records demonstrate the Veteran was granted disability compensation; however, this was not based upon his paranoid schizophrenia but rather based on the residuals of his stroke and arthralgias. Consequently, the Veteran's current unemployability is not the result of his service-connected psychiatric disability. The Board finds, however, that the Veteran's occupational functioning was moderately impaired in that he was not able to work with others due to his social anxiety and paranoia/suspiciousness relating to his coworkers. The evidence demonstrates that the Veteran essentially was able to maintain his employment because he was able to work alone and his bosses were essentially sympathetic to him. As noted by the February 2011 VA examiner, however, the Veteran's behavior at work would not be acceptable at most work places. Furthermore, although the Veteran was able to follow simple commands and do simple tasks, he would not have been able to work at a job where he had to multitask or do complex tasks because of problems with his thought blocking, slow mental processing, focus, concentration, and recent memory. The Board is also aware that the medical evidence shows the Veteran exhibited persistent schizophrenic symptoms such as passivity, negativity and inertia. His affect was persistently blunted. He also exhibited recurrent depressive symptoms, which the examiners have all associated with his service-connected schizophrenia. These symptoms also appear to have affected the Veteran's occupational and social functioning. Furthermore, as early as the September 2007 VA examination, the Veteran began reporting having suicidal thoughts although no suicidal ideation was found at that time of the examinations and nothing was noted in the psychiatric treatment notes. Based upon this evidence, the Board finds that the Veteran's disability picture is more representative of a 70 percent disability rating prior to, as well as after February 10, 2011. A 100 percent disability rating is not warranted, however, because the evidence fails to demonstrate that the Veteran exhibits total occupational and social impairment. The Veteran clearly was able to maintain substantially gainful employment until his stroke in November 2011 despite his moderate to severe psychiatric symptoms. The Board has considered the letter from the VA psychiatrist dated in May 2013 indicating that the Veteran is unable to work; however, it is clear that the opinion was based on a combination of impairment not only from the service-connected psychiatric disorder, but from the nonservice-connected residuals of a stroke as well. Impairment from nonservice-connected disability may not be considered when assigning the rating for a service connected disability. Consequently, the Board finds that the evidence does not demonstrate that the Veteran has had total occupational impairment as a result of his service-connected schizophrenia. As for his social impairment, he was able to maintain a strong relationship with his wife despite having occasional paranoia/suspiciousness towards her. The medical evidence also shows that the Veteran was able to tolerate social situations, such as a family gathering for Thanksgiving and a family trip to Walt Disney World, when necessary; however, he preferred to spend most of his time alone or just with his wife. Consequently, the Board finds that the evidence fails to demonstrate the Veteran has had total social impairment as a result of his service-connected schizophrenia. Total occupational and social impairment having not been shown by the evidence of record, the Board finds that the preponderance of the evidence is against finding that a 100 percent disability rating is warranted. The Board also finds that evidence does not show an exceptional or unusual disability picture as would render impractical the application of the regular schedular rating standards. See 38 C.F.R. § 3.321 (2012). The current evidence of record does not demonstrate that the Veteran's schizophrenia has resulted in frequent periods of hospitalization or in marked interference with employment. Id. It is undisputed that the Veteran's schizophrenia has had an adverse effect on employability, but it bears emphasis that the schedular rating criteria are designed to take such factors into account. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the very problems reported by the Veteran are specifically contemplated by the criteria discussed above. 38 C.F.R. § 4.10. Therefore, given the lack of evidence showing an unusual disability picture not contemplated by the rating schedule, the Board concludes that a remand to the RO for referral of this issue to the VA Central Office for consideration of an extraschedular evaluation is not warranted. For the foregoing reasons, the Board finds that a 70 percent disability rating, but no higher, is warranted for the Veteran's service-connected schizophrenia, paranoid type. To the extent that a disability rating higher than 50 percent was not assigned prior to February 10, 2011, the Veteran's claim is granted. However, it is denied to the extent that a disability rating in excess of 70 percent is not warranted. ORDER Entitlement to a disability rating of 70 percent, but no higher, for schizophrenia, paranoid type, is granted for the period prior to February 10, 2011, subject to controlling regulations governing the payment of monetary benefits. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs