Citation Nr: 1323878 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 05-07 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for a psychiatric disability. 2. Entitlement to an initial compensable rating for menorrhagia with anemia. 3. Entitlement to a total disability rating due to individual employability resulting from service connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1979 to September 1983 and from June 1986 to June 2002. This case comes before the Board of Veterans' Appeals (Board) on appeal from September 2003 and May 2004 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which granted entitlement to service connection for depression and anxiety, with a 30 percent disability rating assigned, effective July 1, 2002, granted entitlement to service connection for menorrhagia with anemia, with a noncompensable rating assigned, effective July 1, 2002, and denied entitlement to a TDIU. The Board remanded the claims in September 2009 and April 2011 for additional development. The claims are now returned to the Board for further appellate action. The appeal was certified back to the Board in April 2012 and, in May 2012, the Veteran's representative submitted additional evidence. However, she waived the Veteran's right to have the RO initially consider this evidence in a statement dated in May 2012. 38 C.F.R. §§ 20.800, 20.1304 (2012). The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disorder claim includes any mental disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009); see also Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disorder and a service-connected disability in the absence of medical evidence that does so, although the Board may not ignore such distinctions where they appear in the medical record). The evidence of record establishes that the Veteran has several psychiatric diagnoses. The competent medical evidence does not differentiate the Veteran's psychiatric symptoms. Thus, the Board has recharacterized the disability as a psychiatric disability, and has considered the totality of all of the Veteran's psychiatric symptoms in deciding this claim on the merits. The issue of entitlement to service connection for chronic obstructive pulmonary disease (COPD) has been raised by the Veteran's representative in a May 2012 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. From July 1, 2002, to December 15, 2004, the credible evidence establishes that the Veteran's psychiatric disability was manifested by occupational and social impairment with reduced reliability and productivity. 2. Since December 16, 2004, the credible evidence establishes that the Veteran's psychiatric disability has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. From September 24, 2004, to March 24, 2008, the credible evidence establishes that the Veteran's menorrhagia with anemia was manifested by hemoglobin 10 gm/100 ml (i.e., 10 gm/1 dL) or less with findings such as weakness, easy fatigability and headaches. 4. Prior to September 24, 2004, and since March 25, 2008, the credible evidence establishes that the Veteran's menorrhagia with anemia was manifested by hemoglobin levels higher than 10 gm/100 ml. CONCLUSIONS OF LAW 1. From July 1, 2002, to December 15, 2004, the criteria for an initial evaluation of 50 percent, but no higher, for the psychiatric disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9434 (2012). 2. Since December 16, 2004, the criteria for an initial evaluation in excess of 30 percent for the psychiatric disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9434 (2012). 3. From September 24, 2004, to March 24, 2008, the criteria for an initial evaluation of 10 percent for menorrhagia with anemia have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.117, Diagnostic Code 7700 (2012). 4. Prior to September 24, 2004, and since March 25, 2008, the criteria for an initial compensable evaluation for menorrhagia with anemia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.117, Diagnostic Code 7700 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act (VCAA) defines VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between a Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ (in this case, the RO). Id.; see Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in a June 2003 letter, issued prior to the rating decision on appeal, VA provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, to include what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The increased rating claims arise from the initial awards of service connection. In Dingess, the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see 38 C.F.R. § 3.159(b)(3)(i). Thus, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file includes VA and private treatment records, statements from the Veteran and her representative, and VA examination reports. The Board notes that the Veteran's representative, in a May 2012 statement, noted that the last VA examination occurred in June 2010 and suggested that the Veteran's menorrhagia with anemia may have worsened since that examination. The Veteran's representative requested that the issue be remanded for a new examination. The need for a more contemporaneous examination occurs only when the evidence indicates the current rating may be incorrect. 38 C.F.R. § 3.327(a) (2012). Here, the most recent VA compensation examination of the Veteran's menorrhagia with anemia was in June 2010. The report of that evaluation contains all findings needed to properly evaluate her disability. 38 C.F.R. § 4.2. Additionally, there is no evidence in the claims file, to include statements from the Veteran, showing a worsening of the menorrhagia with anemia. Consequently, another examination to evaluate the severity of this disability is not warranted because there is sufficient evidence already of record to fairly decide this claim insofar as assessing the severity of the disability. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Olsen v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); and Allday v. Brown, 7 Vet. App. 517, 526 (1995). As discussed above, the Veteran was notified and aware of the evidence needed to substantiate the claims, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by responding to notices, submitting evidence, and providing argument. Thus, she was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Conway, supra; Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). The Board is also satisfied as to substantial compliance with its September 2009 and April 2011 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The remands included scheduling the Veteran for another VA examination for her menorrhagia with anemia, which she had in June 2010. The remands also included scheduling the Veteran for a VA examination for her psychiatric disability, which was scheduled in June 2010. Prior to the examination, in February 2010 and May 2010, the Veteran was sent a letter regarding the consequences of failing to report for the examination. Nonetheless, the Veteran failed to report for the examination. The Veteran was also sent a letter in June 2010, following the scheduled examination, asking if she had good cause for failing to report to the examination. The Veteran did not respond to the letters, and has not provided good cause for her absence. 38 C.F.R. § 3.655(b) (2012). The Board finds that the Veteran was given proper due process for providing evidence of good cause for her failure to report for the examination, to include requesting that a new examination be scheduled. For example, in the June 2010 letter, the RO informed the Veteran that if she had a valid reason for missing the examination or if she wanted to have her examination rescheduled, she should contact VA within 10 days. This letter was sent to the same address shown on an April 2010 report of contact, which means it was sent to the Veteran's last known address. In December 2010, the RO found out that the VA Medical Center had a different address for the Veteran. "Same street as before but a different city. Phone number is also different." The employee further noted that the Veteran had changed her last name. Thus, the employee asked that the Veteran be contacted to see if she wanted to appear for a VA examination. This letter was sent to the Veteran in December 2010. No response was received. In January 2011, VA attempted to contact the Veteran by phone, and there was no answer. The RO sent the Veteran a supplemental statement of the case in January 2011, which laid out her failure to report for the VA examination and its attempts to contact her regarding this failure. There is no indication in the file that any of these letters sent to the Veteran were returned as undeliverable. Thus, she is presumed to have received them. The remands also included obtaining the Veteran's recent VA and private records, which were obtained and associated with the claims file. Finally, the remands included sending the Veteran VCAA notice letters in November 2009 and May 2011, allowing her an opportunity to submit additional medical or other evidence in response (which she did), and then readjudicating her claims in the January 2011 and March 2012 Supplemental Statements of the Case (SSOCs). Thus, there has been substantial compliance with the Board's prior remand directives, and no further remand to satisfy the duty to notify and assist is necessary. See Dyment, 13 Vet. App. at 146-47; Stegall, 11 Vet. App. at 268. General Regulations and Statutes The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2012). 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 disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the Veteran has expressed dissatisfaction with the assignment of an initial ratings following the initial awards of service connection for those disabilities, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. See Fenderson, 12 Vet. App. at 119. Psychiatric Disability The Veteran is currently in receipt of an initial disability rating of 30 percent for her psychiatric disability since July 2002 under Diagnostic Code 9434. 38 C.F.R. § 4.130. She asserts that her symptoms warrant a higher rating. Under Diagnostic Code 9434, the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provide the following ratings for psychiatric disabilities: A 30 percent evaluation is warranted if 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; and, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted if 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; and, difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted if 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 worklike setting); and, inability to establish and maintain effective relationships. A 100 percent evaluation is warranted if 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. 38 C.F.R. § 4.130. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Similarly, in a recent decision, the Federal Circuit focused on this language from the rating criteria for mental health disabilities: "[o]ccupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood" - the criteria for the 70 percent rating. 38 C.F.R. § 4.130. The Federal Circuit held that: [I]n the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Therefore, to the extent that the Veterans Court implied that the listed "areas" were irrelevant to the 70 percent disability determination, this was error. Although the [V]eteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the [V]eteran's level of impairment in "most areas." At the end of this opinion, the Federal Circuit stated that, "Entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). One factor that may be considered 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)); see Richard v. Brown, 9 Vet. App. 266 (1996). Throughout the appeal, the Veteran's GAF scores have ranged from 35 to 55. GAF scores ranging from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A GAF score of 41 to 50 indicates serious symptoms and serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep job), while a GAF score of 31 to 40 indicates major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). See DSM-IV. The Board is cognizant that a GAF score is not determinative by itself. As indicated, the Veteran failed to report for the scheduled VA examination in June 2010 to assess the severity of her service-connected psychiatric disability. This examination was requested by the Board in its remand and found to be necessary to determine the current severity of the Veteran's psychiatric disability. The Veteran has not shown good cause for her failure to report. The Board observes that the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The failure to report to a scheduled examination, without good cause, may result in a denial of a claim for a higher initial disability rating (an original claim), as the claim will be considered on the basis of evidence of record. See 38 C.F.R. § 3.655. When a claimant deliberately fails to cooperate with VA in the development of the medical evidence, VA is entitled to rely on the evidence of record in making its determination. 38 C.F.R. § 3.655(a) (2012). See Kowalski v. Nicholson, 19 Vet. App. 171, 178 (2005). After careful consideration of all evidence, the Board finds that a 50 percent initial disability rating for the service-connected psychiatric disability, but no higher, is warranted from July 1, 2002 (the date of the claim), to December 15, 2004. In this respect, the credible lay and medical evidence shows that the Veteran's service-connected psychiatric disability has resulted in 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; and, difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. Specifically, regarding occupational impairment, in a July 2003 statement, the Veteran stated that she had lost her job as a pizza delivery person in September 2004 due to her psychiatric symptoms. At a June 2004 VA treatment visit, the VA psychiatrist found that the Veteran had made attempts to sustain employment, but the severity of her symptoms made it difficult for her to maintain any type of steady employment. The psychiatrist also noted that on one or more occasions, the Veteran's psychiatric symptoms had led to her dismissal from her prior employment. Regarding social impairment, in April 2003, she reported feeling more anxious that day and frustration due to family dysfunction. At a June 2004 VA treatment visit, a VA psychiatrist found that the Veteran was "sufficiently impaired by virtue of her affective symptoms and social phobia and paranoid ideation in strange or public places that she [was] rendered much more disabled than is apparent." Additionally, at a March 2003 VA treatment visit, the Veteran reported isolation and lack of social interests. At the August 2003 VA examination, the Veteran described a decline in her interest in social activities because of her psychiatric symptoms. Further, the enumerated symptoms for the 50 percent disability rating are also shown by the record. Specifically, at an August 2002 private treatment visit, the Veteran was diagnosed with depression and noted to have no desire to get out of bed. At a December 2002 VA treatment visit, the Veteran was going through a divorce and reported that she would rather be dead, but denied current suicidal ideation, planning or intent. In April 2003, the Veteran was admitted to a private psychiatric hospital due to threats of suicide, but then when she was admitted to the hospital, she denied any such current thoughts. At an April 2003 VA treatment visit, she reported she was feeling more anxious. She expressed frustration at her family dysfunction (her daughter was addicted to pain killers and refused to get help) and complained of depression, anxiety, poor sleep and crying spells. At the August 2003 VA psychiatric examination, the Veteran reported symptoms of insomnia, apathy, hypervigilance, concentration problems, avoidance, decreased energy, decreased motivation, and dysphoric mood. The examiner described her speech as circumstantial. At the March 2004 VA psychiatric examination, the Veteran reported difficulty keeping jobs, difficulty dealing with stress, and almost constant anxiety. The March 2004 found that the Veteran demonstrated severe dysphoria, severe depression, and suicidal ideation. At a June 2004 VA treatment visit, the Veteran experienced recurrent ruminations regarding how it would be to cease living. The June 2004 VA psychiatrist found that the Veteran's recurrent and disabling psychiatric attacks impede her ability to deal with her day-to-day affairs. In December 2004, the Veteran reported worsening anxiety. Thus, the Board finds that the aforementioned evidence establishes that the Veteran's psychiatric disability causes occupational and social impairment with reduced reliability and productivity, so as to warrant the higher 50 percent rating from July 1, 2002, to December 15, 2004. 38 C.F.R. § 4.130, Diagnostic Code 9434. The Board recognizes that the Veteran's psychiatric disability is not manifested by all of the enumerated symptoms for the 50 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9434. However, as previously stated, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442-43. Further, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate equivalent rating will be assigned. Id. at 443. In reviewing the evidence of record, the Board finds that the evidence establishes that the Veteran's psychiatric disability more nearly approximates occupational and social impairment with reduced reliability and productivity, even though the psychiatric disability is not manifested by the entire list of symptoms under the rating criteria. Particularly, the Board notes that the Veteran's GAF scores have ranged from 35 to 56, indicating moderate to major impairment in social and occupational functioning. The Board finds that the overall medical and lay evidence of record supports these GAF scores, and establishes that the Veteran's psychiatric disability causes occupational and social impairment with reduced reliability and productivity. Accordingly, in applying the aforementioned case law, and in resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's psychiatric disability is best rated as 50 percent disabling from July 1, 2002, to December 15, 2004. 38 C.F.R. § 4.130, Diagnostic Code 9434. However, the Board is of the opinion that the Veteran has not met the schedular criteria for a 70 percent rating under Diagnostic Code 9434 from July 1, 2002, to December 15, 2004. During this appeal period, the Veteran's psychiatric disability has not been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Regarding social impairment, in March 2003, a VA examiner noted that she was alert, tense, restless, not psychotic, not suicidal, and not homicidal. In March and April 2003, a VA examiner described her as cooperative, pleasant, coherent and logical. The Veteran was hospitalized in April 2003. While she had presented to the emergency room with thoughts of hurting herself, when she was admitted, she denied any current thoughts. See Final Discharge Summary. She was there for three days and by the date of her discharge, the examiner specifically noted she was not depressed, not psychotic, and not manic. The Veteran denied both suicidal and homicidal ideations, hallucinations, delusions, paranoia, obsessions and compulsions. Thus, while she may have had more severe symptoms at admission, within three days those symptoms were no longer there. The 50 percent rating contemplates exacerbations. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability."). At the August 2003 VA examination, the Veteran reported close relationships with her children and boyfriend and one friend. At that time, she was noted to be devoid of any current auditory or visual hallucinations. There was no evidence of delusional content, and she denied homicidal and suicidal ideations. Her memory was slightly impaired. The August 2003 VA examiner found that, in terms of the Veteran's social adaptability and interactions with others, the Veteran was moderately impaired by her psychiatric symptoms. The March 2004 VA examiner also found that the Veteran's psychiatric symptoms resulted in a moderate degree of impairment in the Veteran's adaptation, interaction, and social functioning. The VA and private treatment records do not provide contrary evidence. Regarding occupational impairment, an April 2003 VA treatment record shows that the Veteran had missed work for one week because she had been hospitalized for issues with her menstrual cycle (versus the service-connected psychiatric disorder). The Veteran was complaining of missing work and possibly losing her job as a result; however, she was attributing her absence at work to her menstrual cycle problems. The August 2003 VA examiner found that, in terms of the Veteran's ability to maintain employment and perform job duties in a reliable, flexible and efficient manner, the Veteran was moderately impaired by her psychiatric symptoms. The March 2004 VA examiner also found that the Veteran's psychiatric symptoms resulted in a moderate degree of impairment in flexibility and efficiency for the Veteran in an occupational setting. At a June 2004 treatment visit, a VA psychiatrist found that the Veteran was "virtually unemployable for any sustained occupation." However, the VA psychiatrist did not indicate that this unemployability was due solely to the Veteran's psychiatric disability. The June 2004 VA psychiatrist also stated that, "For VA purposes [the Veteran] should be considered totally and permanently disabled since she poses a real risk of suicidal behavior if unnecessarily stressed." However, at that time, the Veteran was experiencing the death of her husband, which had occurred in March, which death she had described as sudden. The examiner described her as being in a state of mourning. Exacerbations of symptoms are contemplated by the Rating Schedule. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified 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."). Regarding being totally and permanently disabled, this is contemplated by the claim of entitlement to a TDIU, which considers all of the service-connected disabilities and is addressed in the Remand below. Upon further development, a determination will be made as to whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of both of her service-connected disabilities. The VA and private treatment records do not provide contrary evidence. Additionally, regarding the enumerated symptoms for the 70 percent rating, the evidence of record does not establish that the Veteran has: 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; spatial disorientation; neglect of personal appearance and hygiene; or, inability to establish and maintain effective relationships. Thus, these examples of the level of impairment are not present to support a 70 percent evaluation for occupational and social impairment with deficiencies in most areas. 38 C.F.R. § 4.130, Diagnostic Code 9434. The Board has also considered the GAF scores assigned from July 1, 2002, to December 15, 2004. The aforementioned evidence is also supported by her GAF scores that never fell below 30, in which case would have been indicative of and supportive of the 70 percent rating. Her GAF scores have been indicative of moderate to major impairment of social and occupational functioning, which is more consistent with the criteria for a 50 percent rating under Diagnostic Code 9434. Id. As instructed in Mauerhan, the Board must consider the totality of the Veteran's symptomatology and circumstances when adjudicating the appropriate schedular rating under Diagnostic Code 9434. In this regard, the medical evidence supports the Veteran's GAF scores showing moderate to severe symptomatology. The August 2003 and March 2004 VA examiners found that the Veteran's overall psychiatric symptoms were moderate. A December 2004 VA psychiatrist characterized the Veteran's psychiatric disability as moderate, following a physical examination of the Veteran. Thus, in the opinion of the Board, the Veteran has not demonstrated the type of severity, frequency and duration of psychiatric symptomatology, which would support a 70 percent schedular rating premised on occupational and social impairment with deficiencies in most areas. Id. In summary, the Board finds that the criteria for a 50 percent schedular rating for the service-connected psychiatric disability, but no higher, have been met from July 1, 2002, to December 15, 2004. Id. Furthermore, the Board is of the opinion that the Veteran has not met the schedular criteria for a 50 percent rating under Diagnostic Code 9434 since December 16, 2004, and thus an initial evaluation in excess of 30 percent as of that date is not warranted. Since that time, the Veteran's psychiatric disability has not been manifested by occupational and social impairment with reduced reliability and productivity. Specifically, the Veteran was seen for VA treatment on December 16, 2004, and reported not feeling depressed. Following this treatment, there is an absence of evidence between January 2005 and October 2007. When the Veteran returned to the VA healthcare system in 2007, she was not treated for psychiatric symptoms, but rather other symptoms. Upon reviewing the records after her return to VA, the Board finds that the Veteran's psychiatric symptoms had definitely improved. For example, in May 2008, a VA psychiatrist found that the Veteran's psychiatric symptoms were best characterized as moderate. In May 2010, the Veteran was seen by a VA psychiatrist who found the Veteran's symptoms to be moderate. In January 2011, a VA psychiatrist characterized the Veteran's symptoms as mild to moderate. Additionally, regarding the enumerated symptoms for the 50 percent rating, the evidence of record does not establish that, since December 16, 2004, the Veteran's psychiatric disability has manifested symptoms of: 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; or, impaired abstract thinking. Thus, these examples are not present to support a 50 percent evaluation for occupational and social impairment occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130, Diagnostic Code 9434. The Board notes that in April 2011 and May 2011, a VA psychiatrist characterized the Veteran's symptoms as severe without psychotic features. However, following these treatments, the Veteran was then again not seen by VA (or anyone else) for psychiatric treatment. Thus, the Board is unable to determine whether the Veteran's severe symptoms continued. In this regard, as previously mentioned, the Veteran failed to report for the VA examination following the Board's 2009 remand for this specific purpose. A claimant has an obligation to cooperate in the development of evidence pertaining to her claim, and the failure to do so puts the claimant at risk of an adverse adjudication based on an incomplete and underdeveloped record. See Kowalski, 19 Vet. App. at 178. Thus, without a recent VA examination and without recent VA treatment records (despite the Board's attempts to obtain these records), the Board finds that, even with the 2011 treatment records, the Veteran's symptoms are contemplated based on 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability."). The Board has also considered the GAF scores assigned since December 15, 2004. However, the Board assigns more probative value to the actual clinical findings than a cursory assignment of a GAF score. And, again, the Veteran failed to report for the remanded VA examination, so evidence that could have been favorable to her claim could not be obtained. See Kowalski, 19 Vet. App. at 178. The aforementioned evidence is also supported by her GAF scores that never fell below 30, in which case would have been indicative of and supportive of a higher disability rating. Id. As instructed in Mauerhan, the Board must consider the totality of the Veteran's symptomatology and circumstances when adjudicating the appropriate schedular rating under Diagnostic Code 9434. In this regard, the medical evidence supports the Veteran's GAF scores showing moderate to severe symptomatology. In May 2008, a VA psychiatrist found that the Veteran's psychiatric symptoms were best characterized as moderate. In January 2011, a VA psychiatrist characterized the Veteran's symptoms as mild to moderate. In April 2011 and May 2011, a VA psychiatrist characterized the Veteran's symptoms as severe without psychotic features. The VA and private treatment records do not provide contrary evidence, and more medical evidence could not be obtained since the Veteran failed to report the scheduled VA examination. Thus, in the opinion of the Board, the Veteran has not demonstrated the type of severity, frequency and duration of psychiatric symptomatology, which would support a 50 percent schedular rating premised on occupational and social impairment with reduced reliability and productivity. Id. In summary, the Board finds that, since December 16, 2004, the criteria for a schedular rating in excess of 50 percent for the service-connected psychiatric disability have not been met. Id. The Board notes that in adjudicating a claim the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what she observes or experiences. For example, she is competent to report that she experiences certain symptoms, such as anxiety, and she is credible in this regard. See Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent and credible belief that her disability is worse than the assigned ratings, however, is outweighed by the competent and credible medical examinations which evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the clincal findings than in the Veteran's lay statements. The Board finally does not find evidence that the Veteran's disability evaluation should be increased for any separate period based on the facts found during the appeal periods. The evidence of record supports the conclusion that she is not entitled to an evaluation greater than 50 percent from July 1, 2002, to December 15, 2004, or greater than 30 percent since December 16, 2004. See Fenderson, 12 Vet. App. at 119. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1) (2012). The Court has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the Veteran has only required one hospitalization for her psychiatric disability during the appeal periods, which does not amount to frequent hospitalizations. The Veteran is currently unemployed, which she alleges is due to her psychiatric symptoms. However, to date, no physician has determined that the Veteran's unemployment is due to her psychiatric disability. Even if the Board accepted that as true, it would still find that the current evaluations contemplated these symptoms. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified 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."). The manifestations of the psychiatric disability throughout the appeal are entirely contemplated by the schedular criteria. As shown above, the rating criteria for the psychiatric disability addresses occupational and social impairment. There is no indication that the average industrial impairment from the disability would be in excess of those contemplated by the assigned ratings. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. For the reasons stated above, the Board finds that an initial evaluation of 50 percent, but no higher, from July 1, 2002, to December 15, 2004, is warranted. However, the preponderance of the evidence is against the assignment of a rating in excess of 50 percent for the service-connected psychiatric disability from July 1, 2002, to December 15, 2004, and a rating in excess of 30 percent since December 16, 2004. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Menorrhagia with Anemia The Veteran is currently in receipt of an initial noncompensable disability rating for her menorrhagia with anemia since July 2002 under Diagnostic Code 7700. 38 C.F.R. § 4.117. She asserts that her symptoms warrant a higher rating. Diagnostic Code 7700 provides ratings for hypochromic-microcytic and megaloblastic anemia, such as iron deficiency and pernicious anemia. Anemia with hemoglobin 10 gm/100 ml or less, asymptomatic, is rated noncompensably (0 percent) disabling. Anemia with hemoglobin 10 gm/100 ml (i.e., 10 gm/1 dL) or less with findings such as weakness, easy fatigability or headaches, is rated 10 percent disabling. Anemia with hemoglobin 8 gm/100 ml (i.e., 8 gm/1 dL) or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath, is rated 30 percent disabling. Anemia with hemoglobin 7 gm/100 ml (i.e., 7 gm/1 dL) or less, with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia (100 to 120 beats per minute) or syncope (three episodes in the last six months), is rated 70 percent disabling. Anemia with hemoglobin 5 gm/100 ml (i.e., 5 gm/1 dL) or less, with findings such as high output congestive heart failure or dyspnea at rest, is rated 100 percent disabling. A Note to Diagnostic Code 7700 provides that complications of pernicious anemia, such as dementia or peripheral neuropathy, are to be rated separately. 38 C.F.R. § 4.117. In applying the aforementioned law to the facts of the case, the Board finds that the Veteran's menorrhagia with anemia warrants a higher 10 percent rating from September 24, 2004, to March 24, 2008, under Diagnostic Code 7700. 38 C.F.R. § 4.117. During that time period, the Veteran's menorrhagia with anemia was manifested by hemoglobin 10 gm/100 ml (i.e., 10 gm/1 dL) or less with findings such as weakness, easy fatigability and headaches. Specifically, on September 24, 2004, the Veteran's hemoglobin levels were 5.9 gm/1 dL at a VA treatment visit. In the December 2004 VA Form 9, Appeal to the Board, the Veteran reported that she had symptoms such as weakness, headaches, and heavy loss of blood during menstruation. A December 2004 VA hemoglobin level test revealed 6.2 gm/1 dL. At VA treatment visits in December 2004, the Veteran stated that she was unable to tolerate the anemia medication in any form due to nausea and emesis. The Veteran reported symptoms of constipation, weakness, heavy periods, headaches with vision problems and light and sound sensitivity, dizziness, and feeling bad. The Veteran was diagnosed with low hemoglobin levels. There are no further blood tests revealing the Veteran's hemoglobin levels until March 25, 2008, when the Veteran's hemoglobin levels were 16.9 gm/1 dL at a VA treatment visit. Thus, in applying the aforementioned case law, and in resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's menorrhagia with anemia is best rated as 10 percent disabling from September 24, 2004, to March 24, 2008. 38 C.F.R. § 4.117, Diagnostic Code 7700. However, the Board is of the opinion that the Veteran has not met the schedular criteria for a compensable disability rating under Diagnostic Code 7700 for her menorrhagia with anemia prior to September 24, 2004, and since March 25, 2008. 38 C.F.R. § 4.117, Diagnostic Code 7700. In this respect, since filing her service connection claim in July 2002, the evidence reveals that the Veteran's hemoglobin levels were 11.1 gm/1 dL at a December 2002 VA treatment visit. A June 2003 VA blood test revealed hemoglobin levels of 10.5 gm/1 dL. At the August 2003 VA examination, new blood tests were not taken, and the examiner instead referred to the June 2003 VA results. A blood test was not conducted at the March 2004 VA examination, and the VA and private treatment records dated prior to September 2004 do not provide any further lab results. Thus, the first indication of hemoglobin levels warranting a compensable disability rating was on September 24, 2004, at the VA Medical Center, in which the Veteran's hemoglobin levels were 5.9 gm/1 dL. The Veteran's hemoglobin levels continued to remain low until March 25, 2008, when the Veteran's hemoglobin levels were 16.9 gm/1 dL at a VA treatment visit. The Veteran's subsequent hemoglobin levels remained above 10 gm/1 dL, thus warranting the noncompensable disability rating. Specifically, in April 2008, VA lab results revealed hemoglobin levels of 14.8 gm/1 dL. VA lab results in September 2008 revealed hemoglobin levels of 17 gm/1 dL. At the June 2010 VA examination, the May 2010 lab results (obtained for purposes of the examination) revealed hemoglobin levels of 16.1 gm/1 dL. Further VA lab results taken in May 2010 and June 2010 indicated hemoglobin levels of 14.4 gm/1 dL, 13.8 gm/1 dL, 14 gm/1 dL, and 14.2 gm/1 dL. The remaining VA and private treatment records do not provide any contrary evidence. The Board has considered the application of the remaining diagnostic codes under the current version of the regulation in an effort to determine whether a higher rating may be warranted for the Veteran's menorrhagia with anemia, but finds none are raised by the medical evidence. The Board notes that in adjudicating a claim the competence and credibility of the Veteran must be considered. See Buchanan, 451 F.3d at 1331; Washington, 19 Vet. App. at 368-69. The Board acknowledges that the Veteran is competent to give evidence about what she observes or experiences. For example, she is competent to report that she experiences certain symptoms, such as headaches and weakness, and she is credible in this regard. See Layno, 6 Vet. App. at 465. The Veteran's competent and credible belief that her disability is worse than the assigned ratings, however, is outweighed by the competent and credible medical examinations which evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings than in the Veteran's lay statements. The Board finally does not find evidence that the Veteran's disability evaluation should be increased for any separate period based on the facts found during the appeal period. The evidence of record supports the conclusion that she is not entitled to an evaluation greater than 10 percent from September 24, 2004, to March 24, 2008, and greater than 0 percent prior to and thereafter, during any time within the appeal period. See Fenderson, 12 Vet. App. at 119. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Court has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun, 22 Vet. App. at 111. In the case at hand, the record reflects that the Veteran has not required any hospitalizations for her menorrhagia with anemia during the appeal period. The Veteran is currently unemployed; however, she does not allege that her unemployability is due to her menorrhagia with anemia. Further, no physician has determined that the Veteran's unemployment is due to her menorrhagia with anemia. However, even if the Board accepted that as true, it would still find that the 0 and 30 percent evaluations contemplated these symptoms. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified 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."). The manifestations of the menorrhagia with anemia throughout the appeal are entirely contemplated by the schedular criteria. There is no indication that the average industrial impairment from the disability would be in excess of those contemplated by the assigned ratings. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. For the reasons stated above, the Board finds that an initial evaluation of 10 percent, but no higher, is warranted for the menorrhagia with anemia from September 24, 2004, to March 24, 2008. An initial compensable disability rating for the menorrhagia with anemia is denied prior to September 24, 2004, and since March 25, 2008. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim for a higher evaluation, the doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert, 1 Vet. App. at 49. ORDER From July 1, 2002, to December 15, 2004, entitlement to an initial disability rating of 50 percent, but no higher, for the psychiatric disability is granted, subject to the statutory and regulatory provisions governing the payment of monetary benefits. Since December 16, 2004, entitlement to an initial disability rating of 30 percent for the psychiatric disability is denied. Entitlement to an initial disability rating of 10 percent, but no higher, for the menorrhagia with anemia is granted from September 24, 2004, to March 24, 2008, subject to the statutory and regulatory provisions governing the payment of monetary benefits. Entitlement to an initial compensable disability rating for menorrhagia with anemia, prior to September 24, 2004, and since March 25, 2008, is denied. REMAND After a careful review of the claims folder, the Board finds that the Veteran's TDIU claim must be remanded for further action. Regarding the TDIU claim, in light of the award of increased ratings for her two service-connected disabilities, the Board finds that a remand is required in order for the RO/AMC to effectuate this Board decision and to consider the TDIU claim. Accordingly, the case is REMANDED for the following action: After effectuating the increased ratings granted in this Board decision, readjudicate the Veteran's TDIU claim. If the claim remains denied, issue to the Veteran and her representative a Supplemental Statement of the Case (SSOC). Afford them the appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter 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 or by the Court 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). ______________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs