Citation Nr: 1322674 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 10-24 455 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for a dysthymic disorder for the period of May 30, 2008 to July 22, 2012, and in excess of 30 percent thereafter. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from January 1955 to November 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which awarded service connection for a dysthymic disorder and assigned a 10 percent evaluation for that disability, effective May 30, 2008-the date on which he filed his claim for service connection. The Veteran timely appealed his assigned evaluation. The Veteran testified at a Board hearing before the undersigned in July 2012; a transcript of that hearing is associated with the claims file. This case was last before the Board in January 2013 when it was remanded for further development. That development having been completed, the case has been returned to the Board for further appellate review at this time. During the pendency of the remand, the RO/AMC awarded a 30 percent evaluation for the Veteran's dysthymic disorder, effective July 23, 2012, in a May 2013 rating decision. The Board has therefore recharacterized the issue on appeal in order to comport with this award of benefits. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's psychiatric symptomatology is shown to include symptoms such as, or equivalent to: a flattened affect, disturbances of motivation and mood, a depressed mood, chronic sleep impairment, and mild memory loss. 2. The Veteran's symptomatology throughout the appeal period is not shown to include symptoms such as, or equivalent to: circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memories, such as retention of highly-learned material and forgetting to complete tasks; impaired judgment; impaired abstract thinking; and, difficulty in establishing and maintaining effective work and social relationships. 3. The Veteran's psychiatric disorder more closely approximates occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. The Veteran's psychiatric disorder does not preclude obtaining and maintaining substantially gainful employment, and the difficulty his symptoms cause in an occupational setting has already been compensated through his assigned disability evaluation. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 30 percent for dysthymic disorder, for the period of May 30, 2008 to July 22, 2012, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433 (2012). 2. The criteria for an initial evaluation in excess of 30 percent for dysthymic disorder throughout the appeal period have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's increased evaluation claim for his dysthymic disorder arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a July 2012 hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim herein decided. This claim was previously remanded in January 2013, in order for VA treatment records to be obtained, the Veteran to be asked regarding any private treatment that he may be receiving, and to obtain a VA examination of the Veteran's psychiatric disorder. VA treatment records through April 2013 have been associated with the claims file, and the Veteran indicated that he was not seeking any private treatment for his psychiatric condition in a February 2013 correspondence. The Veteran underwent a VA examination for his psychiatric disorder in April 2013, and his claim was readjudicated in a supplemental statement of the case in May 2013. The examination is adequate, and the Veteran does not contend otherwise. Therefore, the Board finds that its remand order has been substantially complied with, and it may proceed to adjudicate upon the merits of this case. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran filed his claim for service connection for a psychiatric disorder on May 30, 2008. The Veteran was service-connected for a dysthymic disorder in a March 2009 rating decision, at which time his psychiatric disorder was evaluated as 10 percent disabling since May 30, 2008 under Diagnostic Code 9433. During the pendency of the appeal, the RO increased that evaluation to 30 percent disabling beginning July 23, 2012-the date of the Veteran's hearing before the undersigned. Initially, the Veteran has averred that the incorrect Diagnostic Code was used and that instead of a dysthymic disorder he should be service-connected for PTSD and evaluated under Diagnostic Code 9411. As noted in the Board's last remand, the Veteran's treatment records do document a diagnosis of PTSD and depression, although he was service-connected for a dysthymic disorder. The Board noted, however, that the record showed that the psychological symptoms under varying diagnoses of PTSD, depression and a dysthymic disorder overlapped and were indistinguishable; the Board finds that such continues to be the case. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). As both PTSD and dysthymic disorder are rated under the General Rating Formula for Mental Disorders, and the Board is unable to distinguish which symptoms are related to the service-connected disability, the Board has evaluated the Veteran on the basis of all his present psychiatric symptomatology. Thus, the Veteran's symptoms are evaluated under the same criteria in this case, regardless of the Diagnostic Code that it is assigned. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, Diagnostic Codes 9411, 9433 (2012). Under Diagnostic Code 9433, which is governed by a General Rating Formula for Mental Disorders, a 10 percent evaluation is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms are controlled by continuous medication. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 30 percent rating is warranted for 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). Id. A 50 percent rating is warranted for 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 warranted for 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for 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; 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. Id. One factor for consideration in evaluating mental disorders is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (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, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect 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). Turning to the evidence in the case, the Board notes that the private treatment records do not demonstrate any treatment for his psychiatric condition; in fact, the Veteran stated in his February 2013 correspondence that he does not receive any private treatment for his psychiatric condition. The Board notes that the Veteran has been seen by VA for psychiatric treatment since March 2008. The Board has reviewed those treatment records and notes that they are generally similar in nature, particularly to the March 2008 initial psychological evaluation. In that evaluation, the Veteran noted that he had marked disturbance with his sleeping, including problems falling and staying asleep. He had recollections of his Vietnam experience. He also experienced mood swings and angered easily; he was tearful and had occasional crying spells. He denied any suicidal or homicidal ideations or psychosis, as well as any hallucinations or delusions; he did experience some mild paranoia, however. He was "reasonably social" but had some anxiety in public. He reported not seeking any treatment for his condition prior to that time and felt that he was doing well in comparison to other veterans who were living in the woods or worse. The Veteran was noted as living with his fourth wife, with two grown children and as being active in church. On examination, the Veteran was well-groomed and alert and oriented to person, time and place. He was cooperative with a normal flow and rate of speech. His mood was depressed and his affect was tearful. His thought content was appropriate and his thought process was linear. He denied hallucinations, illusions, delusions, suicidal ideations, or homicidal ideations. His memory was intact but not formally tested at that time. He had good insight and judgment and his concentration was variable. He was assessed a GAF score of 45, with a 60 in the past. The Veteran was prescribed trazadone for his sleep problems at that time. Generally, the Veteran was seen on an approximate monthly basis throughout the appeal period with very similar notations with regard to symptoms. The Veteran's GAF, however, was generally shown to be 50 by his psychiatrist, S.R.H., and 55 by his psychologist, P.H.W., who performed the initial March 2008 assessment. The Veteran underwent a VA psychiatric examination in March 2009. In that examination, the Veteran reported that he had experienced weekly to daily with a moderate severity the following symptoms: recurrent and intrusive distressing recollections of the evidence, including images thoughts or perceptions; recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring; psychological reactivity to exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; efforts to avoid thoughts, feelings or conversations associated with the trauma; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affect (e.g., unable to have loving feelings); sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or normal life span); difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and, exaggerated startle reflex. The Veteran was noted as previously only endorsed one of the three posttraumatic stress disorder (PTSD) clusters in his VA treatment records, though he also stated that he was distrustful of the RO. He was taking trazodone. He further stated that his family relationships were "up and down" and reported that he was married to his fourth wife and that they celebrated their 19th anniversary. He noted that she would have gotten rid of him a long time ago if she was not such a "gem." He reported "okay" relationships with his two grown children, though one of them died of cancer in 2000. He also stated that he had acquaintances but that he did not have any friends; he was cordial with his acquaintances. He used to be "pretty social" a long time ago, but "now [he] just can't become intimate or have any intimacy with people." He noted that he was a literacy volunteer with his church and that he gardened and spent a lot of time on the computer. He had been retired since eligible by age for retirement in 1999; he was previously employed full-time with the U.S. Forest Service for 10 years without any occupational impairment at that time. On examination, the Veteran did not demonstrate any impairment of thought process or communication. He was well-groomed and cooperative. He had a mildly irritable mood with a flat affect. He denied suicidal or homicidal ideations, hallucinations or delusions at that time. His attention, memory, and judgment were within normal limits. The examiner gave the Veteran several tests, for which the results correlated with a response style that was indicative of intentional or deliberate feigning or exaggeration of symptomatology. He was diagnosed with a dysthymic disorder and assigned a GAF of 75. The examiner noted that the Veteran's psychiatric disorder was controlled by continuous medication and that his signs and symptoms of his psychiatric disorder were not even transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The Board notes that the Veteran's primary treating psychiatrist, S.R.H., disputes the findings that the Veteran is exaggerating or deliberately feigning the severity of his symptomatology, or is otherwise malingering, in the VA treatment records. In a December 2008 statement, the Veteran stated that he did not sleep well, angered easily and felt guilty about things that he witnessed in Vietnam. In the Veteran's June 2010 substantive appeal, he avers that he should be assigned a 50 percent evaluation because he has "depression, sleep impairment, memory loss and concentration difficulties, nightmares and waking with feelings of 'dread' and panic[,] . . . panic attacks more than weekly, impairment of short term memory, disturbances of motivation and mood, and difficulty in establishing and maintain (sic) effective work and social relationships." On July 23, 2012, the Veteran testified in a hearing before the undersigned. The Veteran stated that he was easily agitated and angry about many things in his life, particularly what happened to him in Vietnam and after he returned from Vietnam including the way returning Veterans were treated at that time, but noted that he had learned to keep his mouth and that he did not get into fights, physical or otherwise. He also stated that he had acquaintances, but did not have any friends; he indicated that he tends to isolate himself and to stay away from people. He used to yell at his wife, but that has improved over time. He continued to report sleeping issues and that he will wake up some nights with a feeling of "dread" which will keep him awake for approximately 30 minutes or so before he is able to fall back asleep. He denied any thoughts of suicide during the hearing. More recently, the Veteran was given a psychiatric evaluation in April 2013, at which time a nurse practitioner, C.B., assigned a GAF of 72. During that evaluation, the Veteran reported insomnia and nightmares and thoughts related to his Vietnam experiences. He denied any suicidal or homicidal ideations or intentions and self-rated his mood as 5 out of 10. On examination at that time he was described as neat and cooperative with an "okay" mood and stable affect. He had logical and goal-directed speech with a normal level of consciousness. He was oriented to person, time and place with good memory, attention and concentration. He had average insight and general intelligence; he denied auditory and visual hallucinations or delusions, and suicidal or homicidal plans or ideations. His judgment, subtraction, production and continuity of thought were all good. The Veteran was continued on bupropion and trazodone. The Veteran underwent a VA psychiatric examination in April 2013. In that examination, the Veteran was diagnosed with dysthymic disorder and assigned a GAF of 60. The examiner noted that although his most recent mental health appointment noted a GAF of 72, the nurse practitioner noted symptoms of insomnia and few friends which would put the Veteran more in the range of 60 currently. The Veteran was only diagnosed with a single psychiatric disorder at that time. The examiner noted that the Veteran's occupational and social impairment was due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or his symptoms were controlled by medication. During the examination, the Veteran reported that he married to his fourth wife of 23 years. He stated that they get along but do have some issues, such as his anger, that have challenged them in the past. He stated that he sometimes feels that way, but that with his treatment and medication, he has been able to control his anger. The Veteran gets along well with his live-in mother-in-law. He had two cats, though one was currently missing; he liked his cats. He enjoyed gardening; he tried to exercise by walking but was not doing it consistently. He regularly attended church and sponsored a monthly outreach program by providing a music program. He was also involved as a literacy coordinator at his church. He noted that church was really his only social activity. He grocery-shopped with his wife, though she did most of it, and attempted to hike with his brother whenever he got a chance. Occupationally, the Veteran reported being retired since 1999 because he was eligible for retirement by age; he has not worked since that time. That job was as a prosecutor in Job Corps in Washington State, where he determined if people should get a hearing; he was in that position for 10 years as a standards officer. Prior to that position, he moved around quite a bit, though he spent 14 years as a juvenile specialist in a court, and for 5 years as an international sales representative for a major airline. He noted that he did not trust people and that he did not really want to be around people, which made working difficult. His last job, he noted, was a solitary position. He stated that he had acquaintances, but did not really have any friends at work. With respect to the Veteran's treatment, it was noted that he saw a psychologist every 6 to 12 weeks and a psychiatrist every 3 months. He took trazodone for sleep, but did not know if it really helped. He also took bupropion, and was not sure that helped either, though he did notice he was less irritable and less prone to yell at his wife. He also reported being kind of tense all the time and that it took him a while to relax at night in order to try and go to sleep; he had to "will" himself to relax. The examiner noted that the Veteran had a depressed mood, chronic sleep impairment, and mild memory loss, such as forgetting names, directions or recent events. No other symptoms were checked on examination. However, she did note that the Veteran had insomnia which bothered him the most; he reported only getting 4 to 6 hours of sleep per night. He said, "I am afraid to go to sleep." He also reported that he awakens at night with dread and felt a sense of panic. He is then sometimes awake for 30 minutes before going back to bed. These episodes are sporadic and may occur daily, or he may go for days without one. He also was noted as having feelings of guilt over the atrocities he witnessed in Vietnam, particularly his memories of a Vietcong prisoner which haunts him daily. His mood was variable and that he does not ever feel joy, but is occasionally happy, such as in his ministry positions at church. He can put a positive light on things that happen, and some days he awakens in an energetic state and is motivated to go outside and work in the garden. Other days he is not motivated at all. He reported his concentration is "ok" for the most part, but he is not always able to remember what he reads and "put it together." He felt his short term memory had declined somewhat. He reported, not recently, feeling like he heard voices, though he could not recognize the voice and knew it was not real. He reported that sometimes his mind will go blank. The examiner noted that the Veteran was alert and fully oriented. He was neatly groomed and cleanly dressed. He was cooperative and polite, with a speech normal in rate, volume and rhythm. His thought process was logical, linear, and goal-directed. His mood was depressed with a congruent affect. There was no observable responsiveness to internal stimuli; he denied hallucinations, delusions and suicidal and homicidal ideations, intent and plans. There was also no observable impairment in attention, concentration or memory. His insight, judgment and impulse control were intact. With regards to unemployability, the examiner concluded that it was less likely a result of his psychiatric disorder. She noted that after review of the claims file and after examination of the Veteran, he did not appear to meet the criteria for unemployability. She noted that the Veteran's functional impairments would cause difficulty, however, with physical or sedentary employment, included: sleep impairment leading to fatigue, increased irritability, and mild memory deficits, as well as his avoidance of other people and desire to be alone. Finally, in a May 2013 statement, the Veteran indicated that he should be rated at 50 percent disabling because he has: intermittently illogical and obscure speech; impaired impulse control with unprovoked irritability with periods of shouting at his wife and getting in her face; an inability to adapt to stressful circumstances; an inability to establish and maintain effective relationships; occupational and social impairment with reduced reliability due to such symptoms as flattened affective, panic attacks and feelings of dread; difficulty in understanding complex commands; difficulty and impairment of short- and long-term memory; disturbances of motivation and mood; and, difficulty in establishing and maintaining effective work and social relationships. He also noted that he had a depressed mood, anxiety, suspiciousness and chronic sleep impairment. He further stated that he felt that the 2009 examiner did not believe him and felt that one of the questions asked on his most recent examination was inappropriate and should not have been asked. He also noted that his one page letter took him over an hour to write because he forgot words and thoughts. On the basis of the foregoing evidence, the Board finds that throughout the appeal period the Veteran demonstrates a flattened affect, disturbances of motivation and mood, as well as a depressed mood, chronic sleep impairment, and mild memory loss. He has also demonstrated a GAF score of as low as 45 and as high as 60, though he is generally assessed either a 50 or 55 throughout the appeal period. Such a finding commensurates to a 30 percent evaluation, but no higher, for his dysthymic disorder throughout the appeal period. The Board notes that the Veteran does not demonstrate any circumstantial, circumlocutory or stereotyped speech; his speech throughout the appeal period is shown to be logical, goal-directed, linear and of normal rate, volume and rhythm. He does not have any impairment in his judgment, abstract thinking or difficulty understanding complex commands. The Board does not that he relates that he has concentration problems, though his concentration is generally noted as being normal or "okay" throughout the appeal period. The Veteran reported sometimes having a hard time "putting things together." While the Board acknowledges this may demonstrate a difficulty in understanding complex commands, the Board does not find that such is a prevalent symptom or a symptom that definitively shows that the Veteran is unable to understand complex commands which would rise to a level of impairment with reduced reliability and productivity. The Board concedes that the Veteran has mild memory loss, but that he does not have impairment of short- and long-term memories, such as impairment retaining highly-learned materials or forgetting to complete tasks, such that his symptoms demonstrate reduced reliability or productivity. The Veteran states that he has panic attacks more than once a week. The Board notes that there is no evidence throughout the appeal period that the Veteran has any panic attacks. While the Board notes that he awakes at night with a "feeling of dread" and is unable to return to sleep for 30 minutes, such is not demonstrable of panic attacks. The Board additionally finds that this symptom is already contemplated by the Board's finding of chronic sleep impairment. The Veteran also avers that he has difficulty establishing and maintaining effective work and social relationships. The Board is cognizant that the Veteran is on his fourth marriage and that he only has "okay" relationships with his two grown children, one of which passed away in 2000. The Veteran additionally has stated repeatedly that he has only acquaintances and no friends, is distrustful of people, and preferred to be alone. The Board contrasts this with the Veteran's ability to work with children for 14 years as a juvenile specialist, as well as working until 1999 without any occupational impairment. He has been married for 23 years to his fourth wife, and works as a literacy coordinator and volunteers with his church once a month to provide a music program, as well as attending church regularly. The Board, therefore, finds that while the Veteran feels he is unable to establish or maintain effective relationships, the evidence of record demonstrates that the Veteran is still able to form some work and social relationships as demonstrated by his long-term marriage and ability to work with people in his church as a literacy coordinator and with an outreach program providing music. Such is qualified as a difficulty in establishing relationships, but it appears that those relationships he does form are effective. Thus, while there is a noted difficulty forming such relationships, the Board does not find that such a difficulty is demonstrable of occupational and social impairment with reduced reliability and productivity. Finally, insofar as the Veteran has stated that he has intermittently illogical or obscure speech, the Board finds no evidence of such in his treatment records or in his examinations. Moreover, the Board does not find that the Veteran's decreasing frequency of "getting in his wife's face" and shouting at her to be impaired impulse control-the unprovoked irritability is linked with periods of violence to demonstrate a level of severity of the symptom-and the Veteran is not shown to have that level of severity throughout the appeal period. Also, as noted above, the Veteran notes that he has difficulty adapting to stressful circumstances and understanding complex commands, but the Board does not find any evidence of such in the record. While the Board is cognizant that the Veteran has stated that he feels that he subjectively has these symptoms indicative of a higher severity, the Board notes that his medical professionals evaluate him very differently than these subjective statements in their professional evaluations. Therefore, the Board finds those professional evaluations to be more probative of the Veteran's actual severity of his psychiatric disorder. In other words, the Board finds that the Veteran is not competent to state whether he actually has these types of symptoms, particularly when it comes to symptoms such as his ability to function in stressful circumstances, understanding complex commands, or whether he has panic attacks or illogical or obscure speech. In short, the Board thinks that the Veteran's own statements in the most recent VA examination regarding his ability sometimes get up and energetically perform his day contrasted against his occasional bouts of non-motivation perfectly capture the Veteran's overall disability picture in this case. Such is more approximate to an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks rather than consistent and continuous impairment with reduced reliability and productivity. As noted above, the Board does find that the Veteran has a flattened affect and disturbances of motivation and mood. He also has a 45 GAF score in March 2008. This evidence is indicative of criteria which would warrant a higher evaluation than the currently-assessed 30 percent. However, the Board has evaluated this evidence in conjunction with the other evidence of record, and finds that such evidence does not raise the overall severity of the Veteran's psychiatric disorder to occupational and social impairment with reduced reliability and productivity, but rather is more approximate to occupational and social impairment with an 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. Accordingly, the Board finds that the Veteran's 30 percent evaluation is warranted throughout the appeal period, and therefore an increase evaluation from 10 percent to 30 percent is warranted for the period of May 30, 2008 to July 22, 2012; however, an evaluation in excess of 30 percent is not warranted throughout the appeal period. See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is adequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected psychiatric disorder, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. Finally, the Board has also considered whether the Veteran is entitled to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In this case, the evidence of record does not indicate that the Veteran is currently unemployed due to his psychiatric disability. The record shows that the Veteran retired in 1999 by reason of eligibility by age and that he has not sought to work following that retirement; prior to his retirement, the Veteran was not suffering any occupational impairment in his job due to his psychiatric disability. The evidence of record does demonstrate that the Veteran would have difficulty functioning in an occupational environment as a result of the above noted psychiatric symptoms. However, the evidence also demonstrates that his psychiatric symptomatology would not preclude obtaining and maintaining substantially gainful employment at this time, should the Veteran wish to engage in such activity. The Veteran has already been compensated through his disability evaluation for that impairment of occupational functioning the result of his psychiatric symptomatology. See 38 C.F.R. § 4.16; Rice v. Shinseki, 22 Vet. App. 447 (2009). (CONTINUED ON THE NEXT PAGE) ORDER Entitlement to a 30 percent evaluation for dysthymic disorder, for the period of May 30, 2008 to July 22, 2012, is granted. Entitlement to an evaluation in excess of 30 percent for dysthymic disorder throughout the appeal period is denied. ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs