Citation Nr: 1325472 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 10-04 580 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to an initial evaluation in excess of 50 percent for anxiety disorder. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1968 to April 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that granted the Veteran's claim for service connection for anxiety disorder with features of posttraumatic stress disorder (PTSD) and depressive features, and assigned a 50 percent initial evaluation, effective May 30, 2008. The Veteran has disagreed with the assigned initial rating. In October 2011, the Veteran testified during a hearing before the undersigned Veterans Law Judge, sitting at the RO. A transcript of that hearing is of record. In a January 2012 decision, the Board denied the Veteran's claim for an initial evaluation in excess of 50 percent for anxiety disorder. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). In March 2013, the Court granted the parties' Joint Motion for Remand (Joint Motion), vacated the Board's January 2012 decision, and returned the case to the Board. FINDING OF FACT The Veteran's anxiety disorder with features of PTSD and depressive features is manifested by symptoms productive of occupational and social impairment comparable to no worse than reduced reliability and productivity. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 50 percent for anxiety disorder with features of PTSD and depressive features have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claim. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, it will assist in substantiating or that is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran is appealing the initial rating assignment as to his anxiety disorder. Because the September 2008 rating decision granted the Veteran's claim of entitlement to service connection for his anxiety disorder, that claim was substantiated. His filing of a notice of disagreement to the initial rating assignment does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2012). Rather, the Veteran's appeal as to the initial rating assignment triggers VA's obligation to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. 38 U.S.C.A. §§ 5104, 7105 (West 2002). Nevertheless, in a June 2009 letter, VA provided notice to the Veteran regarding what is necessary to obtain the maximum benefit allowed by the evidence and the law, setting forth the relevant diagnostic code criteria for rating anxiety disorder (38 C.F.R. §§ 4.130, Diagnostic Code 9413). Thus, the Board finds that VA's duties to notify have been met in this case. The Board also concludes that VA's duty to assist has also been satisfied. The record 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 include VA outpatient treatment records, VA examination reports, statements from friends of the Veteran and his testimony at a hearing before the undersigned. As noted, VA clinical examinations with respect to the issue on appeal have been obtained. 38 C.F.R. § 3.159(c) (4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA clinical examinations obtained in this case are adequate, as they are predicated on a full reading of the medical records in the Veteran's claims file. The examiners considered all of the pertinent evidence of record and clinical findings pertinent to the schedular criteria for rating the disability at issue were obtained. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Board finds that in this case the available evidence of record provides sufficient information to evaluate the level of severity of this disability. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the Board hearing, the VLJ explained the issue on appeal and the evidence necessary to substantiate the Veteran's claim for an increased rating. During the Board's hearing, the Veteran was assisted by an accredited representative from the Vietnam Veterans of America. The representative and the VLJ asked questions to ascertain the current state of the Veteran's service-connected disability, and the hearing focused on the evidence necessary to substantiate the Veteran's claim of increased rating for his anxiety disorder. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or the representative. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim on appeal. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Law and Analysis Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). Where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Service connection for anxiety disorder with features of PTSD and depressive features was granted in a September 2008 rating decision, and a 50 percent initial disability rating was assigned effective May 30, 2008 under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9413. The Veteran filed a timely notice of disagreement in March 2009 and perfected his appeal in January 2010. The Veteran's service-connected anxiety disorder is evaluated as 50 percent disabling under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9413. Ratings are assigned according to the degree of occupational and social impairment resulting from manifestations of the disability at issue. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting; inability to establish and maintain effective relationships.). A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9413. The Board notes that the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to DSM-IV, a GAF score ranging from 31-40 reflects 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; child frequently beats up other children, is defiant at home, and is failing at school). A GAF score of 41-50 reflects 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). GAF score of 51-60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61-70 denotes some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 71-80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). The Veteran asserts a higher rating should be assigned for his service-connected psychiatric disability. He argues his symptoms have increased in severity. He claims he sometimes says inappropriate things and gets irritable toward his wife and that his wife helps him with his personal hygiene. In a statement dated in July 2008, and received in August 2008, G. G. related he had been friends with the Veteran for 50 years. He noted the Veteran had spoken with him about his nightmares and thoughts of suicide. He stated he had observed many outbursts of anger towards others. He noted the Veteran had become more distant and quick-tempered, and excluded himself from social situations. In November 2008, M. R. F. stated he had known the Veteran for several years and said the Veteran displayed an increasing preference towards isolation. He reported the Veteran was hypervigilant and had flashbacks. The Veteran was seen in a Vet Center in June 2008, and asserted he had no interest in activities he previously enjoyed. He related he avoided situations and people that reminded him of the events in Vietnam. Initially, the Veteran was provided a VA psychiatric examination in August 2008. He reported that he did not socialize very often. He interacted in a somewhat inhibited fashion. He reported he had a couple of good friends, that he had been married for 31 years, and that he got along "pretty well" with his spouse. His affect was decreased in range. He indicated he snaps on occasion. He had intermittent feelings of worthlessness and felt hopeless at times as well. He related that about once or twice a week he had unwanted memories of things he experienced in Vietnam. He also reported nightmares about two times a week. The examiner stated the Veteran had some significant signs of depression. He was taking anti-depressant medication. On mental status examination, the Veteran was alert and oriented. He was very polite and appropriate. He denied manic or hypomanic symptoms. He denied recent panic attacks or suicidal ideation. The Veteran also denied hallucinations, delusions and paranoid ideation. The diagnostic impression was anxiety disorder, not otherwise specified, with features of posttraumatic stress disorder with prominent depressive features. The GAF score was 55. The Veteran was afforded another VA psychiatric examination in March 2009. He described his mood as neutral and disinterested. He said he had a depressed mood a few times a week, lasting one to two hours. He related he had low energy and low self-esteem. He described combat-related nightmares once a week and added that he had decreased libido. He noted he had verbal outbursts towards his wife. He had been prescribed anti-depressant medication. On mental status examination, the Veteran was casually dressed. He was not remarkable for psychomotor activity. His speech, thought process, and thought content, were unremarkable. His affect was appropriate. The examiner found that the Veteran had fair impulse control. He was noted to be only mildly depressed. The mental status evaluation revealed he was oriented to person, place and time. He had no delusions or hallucinations. He denied obsessive or ritualistic behavior and panic attacks. There was no suicidal or homicidal ideation and the Veteran was able to maintain minimal personal hygiene. His memory was normal. The GAF score was 63. The examiner stated the Veteran's level of functioning did not seem to have changed significantly since the previous VA examination. In regard to the effects of mental disorder on occupational and social function, the examiner found that the Veteran's mental disorder signs and symptoms did not result in deficiencies in the areas of judgment, thinking, family relations, work, mood or school. The Veteran was afforded a VA psychiatric examination in April 2011, the Veteran claimed his mood was blasé and reported he had crying spells. He was taking anti-depressant medication. He said he thought of the sounds and smells of Vietnam about two times a month. He described some conflict with one of his sons regarding his views of Vietnam. He had been married for 33 years, and described his relationship with his spouse as "usually good." On mental status evaluation, his mood was dysphoric. The Veteran's affect was appropriate. He was not remarkable for psychomotor activity. His speech, thought process, and thought content were unremarkable. He described sleep impairment, noting he had trouble staying asleep. He expressed irritability towards one son and asserted he occasionally "flies off the handle" with his wife. On mental status examination, the Veteran asserted he was being treated only with medication, and had not received any individual psychotherapy. He described his marital relationship as good and that he had good relationships with other family members. There were no delusions or hallucinations. He denied obsessional or ritualistic behavior. There were no panic attacks or suicidal or homicidal ideation. The Veteran was able to maintain minimal personal hygiene. The GAF score was 63. In a May 2011 addendum, the same examiner who conducted the April 2011 VA examination concluded the symptoms of the Veteran's anxiety disorder with features of PTSD and depression were relatively mild and not of such severity as to have any significant impact on the Veteran's ability to work. The examiner noted that the Veteran reported to the examiner that he retired in 2007 after 14 years of work in insurance sales because he no longer wanted to travel out of town in order to spend more time at home with his wife. The examiner noted that the Veteran made no mention of mental health issues as contributing factors in his decision to retire. At his October 2011 hearing before the Board, the Veteran testified that he was almost always depressed. He also reported symptoms of intrusive thoughts and flashbacks of Vietnam. He related that he hid his feelings from his wife, did not see friends often, and preferred to be alone. He had suicidal ideation two months ago. He had been married for 35 years to his wife and described their relationship as "usually good." He stated that he occasionally said a lot inappropriate things to her and then she would "kind of scold me," and he apologized. Occasionally, his wife helped him with his personal hygiene in that she reminded him to change his clothes or brush his teeth when he forgot. He mostly stayed at home, played games on computer, watched television, and performed household chores, such as going grocery shopping or cooking dinner for his wife before she got home from work. He believed that his psychiatric symptoms had gotten a lot worse since he retired from his job and that he now was unable to work in any job due to low motivation. Most recently, the Veteran was provided a VA psychiatric examination in March 2012. The same examiner who conducted the April 2011 VA examination and provided the May 2011 addendum, listed that Veteran's diagnosis of anxiety disorder, not otherwise specified, with features of PTSD and depression, and a GAF score of 63. The examiner found that the Veteran's level of occupational and social impairment with regards to his mental diagnosis was best summarized as "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." Relative to social and family history, the Veteran stated that he lived with his wife of 34 years and described his marital relationship as "pretty good." He had three sons and indicated that he had "real good" relationship with one of them and "fair" relationships with the other two sons. He maintained contact with his sister, but did not see much of his brother. He had a few friends but said "I'm kinda loner." He played golf in the summer months. The examiner reported pertinent symptoms as chronic sleep impairment; mild memory loss, such as forgetting name, directions or recent events; feelings of hopelessness; irritability; intrusive thoughts of Vietnam; and crying spells. On mental status examination, the Veteran was adequately groomed in casual dress and appeared to be alert and well-oriented. His affect was stable. He had logical and coherent thought process and speech. He described his typical mood as "blasi, sometimes I'm mad, don't even know why, usually." He reported occasional irritability towards his wife but did not describe physical aggression. He denied prolonged depressed mood, but reported feelings of hopelessness and stated that he "can cry at the drop of a hat." He did not describe suicidal ideation. His energy level was "low." He denied significant fear or anxiety "because I don't really care." He did not report obsessive-compulsive symptoms or panic attacks. He reported intrusive thoughts of Vietnam "a few times a week," but did not describe combat-related nightmares. He did not report avoidance behaviors. He reported occasional trouble staying asleep and mild memory loss. He was cooperative with the interview. The examiner found that the Veteran was capable of managing his financial affairs. Based on a thorough review of all of the evidence of record, as outlined above, the Board finds that the Veteran's total disability picture most closely approximates the criteria for a 50 percent disability rating. 38 C.F.R. § 4.7 (2012). In reaching this determination, the Board finds it significant that the VA examiners, who conducted a comprehensive psychiatric assessment of the Veteran, diagnosed anxiety disorder, and estimated that his GAF scores were 55 to 63, which, as discussed above, is indicative of no worse than moderate symptoms such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as few friends, conflicts with peers or co-workers. Furthermore, the Veteran's reported symptomatology of depression with intermittent crying spells, irritability and verbal outbursts towards his wife, occasional panic attacks, nightmares, intrusive recollections, flashbacks, occasional trouble staying asleep, hypervigilance, avoidance of trauma-related stimuli, mild memory loss, low motivation, feeling worthless and hopeless, passive and transient suicidal ideation, social withdrawal, variable mood and affect, and fair impulse control, are compatible with a GAF score in the upper 50s or lower 60s. In short, the Board finds that the Veteran's anxiety disorder results in occupational and social impairment productive of no worse than reduced reliability and productivity due to such symptoms as depression with intermittent crying spells, irritability and verbal outbursts towards his wife, occasional panic attacks, nightmares, intrusive recollections, flashbacks, occasional trouble staying asleep, hypervigilance, avoidance of trauma-related stimuli, mild memory loss, low motivation, feeling worthless and hopeless, passive and transient suicidal ideation, social withdrawal, variable mood and affect, and fair impulse control. However, the Veteran's total disability picture does not rise to the severity required for a 70 percent or higher rating. In this regard, the Board finds it significant that there is no indication that the Veteran is delusional, grossly inappropriate, disoriented, in persistent danger of hurting himself or others, or is unable to perform the activities of daily living. The Veteran's thought process and speech were consistently logical and coherent, as evidenced on his VA examinations. He was alert and fully oriented at all VA examinations and found capable of managing his financial affairs. Additionally, the Veteran denied any manic or hypomanic symptoms, delusions, hallucinations, paranoia, obsessive or ritualistic behaviors or homicidal ideation. The Veteran's appearance, hygiene, and behavior were noted as appropriate at all times. In this regard, the Veteran testified at his October 2011 Board hearing that he will "wear the same clothes for 3 to 4 days." It was also noted in a November 2010 informal conference report that "he does not care about his personal hygiene. His spouse has to tell him to clean up." While the Board acknowledges that the Veteran occasionally forgets and needs to be reminded to maintain his personal hygiene, he testified at his Board hearing that it is because he just occasionally forgets to brush his teeth, bathe, or change clothes and not because he has problems motivating himself to do so. Thus, the Board is of opinion that the reported instances for the Veteran's neglect of personal hygiene are not extreme and they seem to be due to forgetfulness, which is in fact not uncommon to a man of the Veteran's age. Furthermore, the VA examiner in March 2009 and April 2011 assessed that the Veteran was able to maintain minimal personal hygiene. The March 2012 VA examination also reflects that he was adequately groomed. The March 2013 Joint Motion questioned the Board finding that there was no evidence of impaired impulse control, citing to evidence of the Veteran's verbal outbursts and irritability towards his wife. Specifically, the August 2008 VA examination report noted that if someone "rubs [the Veteran] the wrong way 'I snap'" and that he tended to "hold things in and then blow up." In the April 2011 VA examination report, the Veteran stated that he "occasionally 'flies off the handle with [his] wife.'" However, the Board finds that while the reported instances may show that the Veteran does not have excellent impulse control, they do not amount to impairment in impulse control. To that effect, the VA examiner, who considered the Veteran's reports of his verbal outbursts towards his wife and irritability toward one of his sons, specifically noted that the Veteran had good to fair impulse control. On the April 2011 VA examination, the Veteran also reported that although he occasionally "flies off the handle with his wife," he came back and apologized. The record is devoid of evidence indicating that the Veteran has had any episode of violence or physical aggression. Similarly, at his October 2011 Board hearing, the Veteran related that he occasionally said a lot inappropriate things to his wife and then she would "kind of scold me," and he apologized. Thus, the extent of anger outbursts or irritability shown by the evidence of record is not so disabling as to amount to "impaired impulse control, such as unprovoked irritability with periods of violence," as provided as an example in the criteria for a 70 percent rating. The March 2013 Joint Motion also found that the Board did not consider the Veteran's thoughts of suicide, and cited to the Veteran's testimony at the October 2012 Board hearing that "[he] had thoughts of suicide. [H]e walked across the bridge back in [his] hometown and - and considered jumping." It was also noted in the November 2010 informal conference report that the Veteran described "past suicidal thoughts with no apparent plan and situations like driving too fast for wet conditions." In the July 2008 letter, the Veteran's friend reported that the Veteran spoke to him about "thoughts of suicide on different occasions." Based on the foregoing evidence, the record does reflect that the Veteran experiences occasional suicidal ideation. However, the Board finds that it is passive and transient in nature because the Veteran denied suicidal ideation at all of his VA examinations in August 2008, March 2009, April 2011 and March 2012. Further, while the Board recognizes suicidal ideation is listed as an example of symptoms warranting a 70 percent evaluation, as discussed above, the symptoms listed in the 38 C.F.R. § 4.130 are not intended to constitute an exhaustive or complete list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan, 16 Vet. App. at 442. In this regard, the Board notes that the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code, but it must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board concludes that the Veteran's anxiety disorder symptomatology affecting the level of his social and occupational functioning level is, at most, in the moderate range in this case. The Board attaches significant probative value to the March 2009 VA examiner finding in regard to the effects of mental disorder on occupational and social function that the Veteran's mental disorder signs and symptoms did not result in deficiencies in the areas of judgment, thinking, family relations, work, mood and school. Rather, in March 2012, the VA examiner concluded that the Veteran's level of occupational and social impairment with regard to his mental diagnosis was best summarized as "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." Pertinent to the Veteran's social functioning, the Board notes that the Veteran has reported that he was increasingly isolating himself socially. However, he reported that he has been married to his wife over 35 years, and although he was occasionally irritable with his wife, he reported a generally positive relationship with her. On the August 2008 VA examination, he reported that he got along "pretty well" with his spouse and that he had a couple of good friends. He related that he did feel close to his wife and one of his friends. On the March 2009 VA examination, he described his marital relationship as good and that he had good relationships with other family members despite the fact that he had some conflict with one of his sons regarding his views of Vietnam. On the March 2012 VA examination, the Veteran reported a "pretty good" relationship with his wife and "fair" to "real good" relationships with his sons. He related that he was kind of a loner but admitted that he had a few friends. At his October 2011 Board hearing, he described his marital relationship as "usually good." Accordingly, while the Veteran has shown difficulty in social relationships, he has also demonstrated that he is able to establish and maintain effective relationships, such as his over 35 year long marriage to his wife and good relationships with other family members and friends. With regard to occupational functioning, the VA examiner in the May 2011 addendum concluded that the Veteran's psychiatric symptoms were "relatively mild" and not of such severity as to have any significant impact on the Veteran's ability to work. This conclusion was supported by the Veteran's report that he retired in 2007 because he no longer wanted to travel out of town in order to spend more time at home with his wife and the fact that he did not mention his mental health issues as a contributing factor in his decision to retire. During the October 2011 Board hearing, the Veteran indicated that his mental health condition had gotten a lot worse ever since his retirement from his job and that he felt he now was unable to work in any job due to low motivation. Nevertheless, based on the VA examiner's assessment of the effects of the Veteran's mental disorder on his occupational functioning, inability or total occupational impairment solely due to his anxiety disorder is not shown. Accordingly, considering the totality of the evidence, and resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran's disability picture more nearly approximates the criteria for the 50 percent disability rating, and therefore the 50 percent rating is the appropriate rating in this case. 38 C.F.R. § 4.7. The evidence does not reflect a disability picture which more nearly approximates a degree of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, or total social and occupational impairment. Id. As such, a 70 percent rating or greater rating is not warranted. Staged ratings have been considered. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected anxiety disorder, the evidence of record does not show a distinct period of time on appeal during which a rating in excess of 50 percent would be warranted for the Veteran's service-connected anxiety disorder. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a 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 and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b) (1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The schedular rating in this case is adequate. The diagnostic criteria contemplate and adequately describe the symptomatology of the Veteran's service-connected anxiety disorder. See Thun, 22 Vet. App. at 115. The Veteran's anxiety disorder is evaluated by the rating criteria which specifically contemplate the level of occupational and social impairment caused by this disability. See 38 C.F.R. § 4.130, Diagnostic Code 9413. When comparing the Veteran's psychiatric symptoms and social and occupational impairment with the schedular criteria, the Board finds that his symptoms are congruent with the disability picture represented by the currently assigned 50 percent rating. Accordingly, a comparison of the Veteran's symptoms and functional impairments resulting from service-connected anxiety disorder with the pertinent schedular criteria does not show that his service-connected anxiety disorder presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular rating is adequate to rate the disability. Based on this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). As such, referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. In sum, the Board finds that the evidence is against the assignment of a rating in excess of 50 percent for anxiety disorder under Diagnostic Code 9413, at any time during the rating period on appeal. While the Veteran is competent to report the symptoms he experiences, and the Board finds him credible in this regard, the reported symptoms are consistent with the schedular evaluation assigned herein. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating greater than 50 percent for anxiety disorder with features of PTSD and depressive features. Consequently, the benefit-of-the-doubt rule is not applicable. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on individual unemployability due to service-connected disability (TDIU), either expressly raised by the veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran submitted a VA Form 21-8940, Application for Increased Compensation Based On Unemployability, in May 2011, and asserted that symptoms of the disability at issue, and other service-connected heart disability, render him totally unemployable. The May 2011 claim of entitlement to a TDIU was adjudicated in a November 2011 rating decision. No appeal was taken from that determination. Accordingly, the Board concludes that a claim for TDIU is not before the Board for appellate consideration. ORDER An initial evaluation in excess of 50 percent for anxiety disorder with features of PTSD and depressive features is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs