Citation Nr: 1330239 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 09-20 785 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased rating, in excess of 50 percent, for depression. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from March 1978 to August 1979. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In June 2010, the Veteran, sitting at the RO, testified during a hearing conducted via video conference before the undersigned. A transcript is of record. FINDING OF FACT Depression is productive of moderate to considerable occupational and social impairment, without deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood or symptoms that are equivalent to those that are examples of symptoms warranting a rating in excess of 50 percent. CONCLUSION OF LAW The schedular criteria for a rating in excess for 50 percent for depression are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code 9434 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). 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; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. Pub.L. 112-154, §§ 504(a)(1)-(2) (to be codified at 38 U.S.C.A. § 5103(a)); 38 C.F.R. § 3.159(b)(1) (20). 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). Adequate VCAA notice in an increased rating claim requires that the claimant be told that to substantiate a claim the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; that should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008); vacated and remanded in part Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In June and September 2008 letters, the agency of original jurisdiction (AOJ) notified the Veteran of information and evidence necessary to substantiate his claim. He was notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. In the June and September 2008 letters, the Veteran was informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); and was given the notice required by the surviving portions of Vazquez-Flores. The AOJ satisfied its duty to notify the appellant under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013) and 38 C.F.R. § 3.159(b). In July 2008, the Veteran underwent VA examination and the examination report is of record. As noted above, in July 2010, the Board remanded the Veteran's case to the RO for further development, that included obtaining VA psychiatric treatment records from the Dorn VA medical center (VAMC) dated since September 2008, including a September 2009 VA examination referenced during his July 2010 Board hearing and records from Dr. Dean .Floyd. There has been substantial compliance with the Board's remand, as the Veteran's recent treatment records from the VAMC in Columbia, including Dorn VA Hospital, dated from May 2009 to September 2011, were obtained. The records, including those dated from January 2009 to January 2010, do not include a September 11, 2009 VA examination report. The records show that the Veteran was examined by VA on July 11, 2008 and that report is in the file. The Board notes that the only reference in the claims file to a September 11, 2009 VA examination is from the Veteran's representative during the June 2010 Board hearing. See Board hearing transcript at page 5. However, the Veteran's medical and other records are completely devoid of any reference to such an examination. Given that the requested VA medical records were obtained, including from the Dorn VA Hospital, for the period in question, and given that the records do not even remotely discuss a September 11, 2009 VA examination, the Board concludes that further remand to obtain a September 2009 VA examination report is not warranted. See e.g., Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (to the effect that the Veterans Claims Assistance Act is a reason to remand many, many claims, but it is not an excuse to remand all claims). In July 2010 and August 2011, the Appeals Management Center asked the Veteran to complete authorizations for it to obtain records of treatment provided by Dean Floyd, M.D. or to provide the records himself. The Veteran did not provide authorizations, but instead submitted summaries from Dr. Floyd, dated in August 2010 and September 2011. VA has no further duties to seek records for which a claimant fails to provide necessary authorizations. 38 C.F.R. § 3.159(c)(1)(ii) (2013). In August 2010, the Veteran underwent VA examination, the examination report is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, examined the Veteran, provided clinical findings and diagnoses, and offered etiological opinions with rationales from which the Board can reach a fair determination. There is no evidence of a change in the disability since that examination. The United States Court of Appeals for Veterans Claims has interpreted the provisions of 38 C.F.R. § 3.103(c)(2) (2013) as imposing two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's hearing the issues were identified, including the evidence needed to substantiate the claim. There was a discussion of possible evidence that could substantiate the claims. That discussion lead to the Board remand for additional records and a new examination. The Board finds the duties to notify and assist have been met. Rating Criteria Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In the case of an increased rating, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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 (2013). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2013). The General Rating Formula for Mental Disorders, including Diagnostic Code 9434, that evaluates major depressive disorder, at 38 C.F.R. § 4.130, provides the ratings for psychiatric disabilities. A 50 percent rating is warranted if the disability is productive 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. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Global Assessment of 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) (citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32). A GAF score of 41 to 50 indicates 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). A GAF score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a 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). When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102; Mauerhan v. Principi, 16 Vet. App. 436 (2002) (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels.). A veteran may only qualify for a given rating based on mental disorder by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Although a veteran's symptomatology is the primary consideration in assessing a disability rating based on a mental disorder, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas" for the 70 percent rating. Vazquez-Claudio v. Shinseki 713 F.3d 112 (Fed. Cir. 2013). Background In a March 2003 rating decision, the RO granted service connection for depression that was assigned an initial 30 percent disability rating. In a February 2007 rating decision, the RO effectuated a January 2007 Board decision that granted a 50 percent rating. In June 2008, the Veteran submitted a claim for an increased rating for depression. VA medical records, dated from January 2005 to September 2011, reflect the Veteran's treatment for depression that included prescribed medication regularly managed by a clinic psychiatrist and occasional individual outpatient therapy. A November 2007 VA mental health treatment plan update indicates that the Veteran's panic attacks were variable and ranged from four to five times a week. He reported that work occasionally made him feel irritable and angry three to four times a week. The diagnosis was depression/anxiety, not otherwise specific (NOS), chronic with panic attacks. When seen in March 2008, the Veteran reported ongoing panic attacks at least every day. His panic attacks occurred more at work with increased workload and his depressive symtoms increased as well. The Veteran worked through contracts and, when a business had to bid on contracts, there was the possibility he would not have a job if his company was outbid. A June 2008 VA mental health medication management note, prepared by the Veteran's treating psychiatrist, reflects that the Veteran had taken a small amount of clonazepam and citalopram several years ago but currently preferred therapy. He worked as a locksmith at Fort Jackson and admitted to feelings of work pressures. It was noted that he took left over clonazepam when stressed but refused resumption of medications. The Veteran's appearance was adequate, his speech was spontaneous, his mood was variable, his thought process was goal-directed, and he was oriented with intact memory and good impulse control, insight, judgment, and concentration. There were no hallucinations. A GAF score of 52 was assigned. In a statement dated in June 2008, a VA psychiatrist reported that the Veteran was treated for major depressive disorder and received regular psychotherapy with a social worker and the coordinator of the posttraumatic stress disorder (PTSD) clinic. The Veteran's symptomatology included, but was not limited to, severe depressive episodes in which he often experienced feelings of anhedonia lacking any interest in activities pertaining to socialization. The Veteran had ongoing sleep disturbance. His condition was exacerbated by feelings of worthlessness or guilt. The Veteran attempted to attend school in the past but admitted to having difficulty concentrating as well as severe long and short term memory impairment. Further, the Veteran had severe impairment in social functioning due to erratic mood swings. He had an apparent concern relating to his inability to get along with others, exhibiting unpredictable behavior, and paranoia that someone was out to get him. It was the VA psychiatrist's observation that the Veteran also had grotesque impairment in areas in which he was forced to interact with others. It was noted that there were situations in which he exhibited unprovoked irritability. He exhibited inappropriate behavior in his daily interaction with family members resulting in their withdrawal from interaction with the Veteran. Additionally, the Veteran demonstrated a great deal of difficulty in adapting to stressful situations in social environments. He had chronic and persistent depressive episodes that contributed to his social isolation and social withdrawal marked by repeated episodes of decompensation through his treatment process each of prolonged duration. In the VA psychiatrist's opinion, the Veteran was unable to sustain and maintain gainful, substantial employment because of his chronic, severe major depressive disorder. In July 2008, the Veteran underwent VA psychological examination. The examiner was unable to review the Veteran's claims file. The Veteran took citalopram that he said was helpful for treating his psychiatric disorder. He tried attending group therapy but it was not very helpful. The Veteran currently had difficulty with a depressed mood, poor motivation, sleep difficulty, decreased energy, loss of libido, anhedonia, anxiety problems, and some difficulty with anger. The Veteran had been married once and continued to live with his wife of 31 years with whom he had three grown children. He had friends with whom he talked. The Veteran did not have much interest in hobbies or activities and, at times, did not have much motivation to complete activities of daily living but completed them anyway. He worked as a locksmith at Fort Jackson for six years. The Veteran had some difficulty with memory and was talked to about his poor performance at work. He also reported having anger problems at work for which he received warnings. On examination, the Veteran was alert and oriented and his thought process was linear. His affect was blunted and insight was demonstrated. Speech was spontaneous and attention was mildly impaired. He denied any difficulty with auditory or visual hallucinations. The Veteran denied homicidal ideation and reported having suicidal thoughts in the past but denied any suicide attempts or current suicidal ideation. The Axis I diagnosis was major depressive disorder and a GAF score of 54 was assigned. The VA examiner noted that the Veteran experienced symtoms of depression, including difficulty with depressed mood, poor motivation, sleep difficulty, decreased energy, loss of libido, anhedonia, anxiety problems, and anger management problems. The examiner opined that the Veteran demonstrated moderate impairment in functioning related to his symtoms of depression. This affected his social functioning including his ability to interact with family and friends. The Veteran had decreased interest in activities or hobbies. He also had mild occupational impairment related to poor performance and anger problems. In a September 2008 statement, Dr. D.A.F. reported without elaboration that he treated the Veteran for panic attacks. An August 2009 VA mental health medication management note shows that the Veteran was evaluated for stable depression/anxiety NOS due to chronic pain with panic attacks by history. He felt stable and no longer needed medications or therapy. The Veteran wanted to be seen yearly for mental status exams. He had a second grandchild whom he and his wife visited and planned to see again. The Veteran had good and bad days and it was currently a good day-he had no complaints. On examination, the Veteran was adequately groomed, his speech was normal, his mood was euthymic, his affect was normal, his thought content was appropriate and his thought process was linear. There were no hallucinations or suicidal or homicidal ideations. The Veteran was oriented, his memory was intact, and concentration, impulse control, insight, and judgment were good. A GAF score of 55 was assigned. In October 2009, VA medical records show that the Veteran telephoned mental health clinicians and reported that he was not suicidal but was very anxious and having panic attacks. Citalopram and clonazepam were prescribed. A May 2010 VA mental health note reflects that the Veteran called his psychiatrist for a medication adjustment for citalopram for maximum benefits. His dosage was increased. According to a July 2010 VA mental health note, the Veteran had previously received outpatient counseling and planned to call the team therapist as needed for counseling for renewed irritability and depression at work and even when on vacation at the beach. He had not refilled his antidepressant citalopram since January and felt it needed to be adjusted. His VA treating psychiatrist increased the dosage and noted that the Veteran needed to be medication-compliant. The Veteran was taking the anti-anxiety medication clonazepam and wanted to continue. On examination, the Veteran was alert, oriented, and tense, with a fair mood. He was preoccupied with feeling stressed out at home and at work. The Veteran planned to apply for disability increase and sought the psychiatrist's assistance. The Veteran denied suicidal and homicidal ideations and hallucinations. His insight and judgment were intact. A GAF score of 49 was assigned. In an Addendum, the psychiatrist noted that the Veteran did not have PTSD symptomatology. In a July 2010 statement, the Veteran's VA treating psychiatrist noted that the Veteran had a diagnosis of depression, anxiety, and insomnia. The Veteran currently took citalopram and clonazepam for psychiatric diagnoses. He experienced irritation, anxiety, and depressive symtoms. In August 2010 and September 2011 statements, Dr. D.A.F. stated that the Veteran was followed for a panic disorder and depression and also received VA treatment. He again did not elaborate. In August 2010, the Veteran underwent VA examination for mental disorders. According to the examination report, the examiner reviewed the Veteran's medical records. It was noted that the Veteran had been receiving VA treatment since 2006 for depression, anxiety, insomnia, and problems with irritability, and been diagnosed as having depression, anxiety, and panic attacks. The Veteran reported that his mental disorder had worsened and that he saw his VA psychiatrist every three to six months. His medication dosages had recently been increased. The Veteran said his medication helped with negative thoughts but sometimes made him more irritable. He did not find group counseling very helpful. The Veteran worked at Fort Jackson as a locksmith and was there for fifteen years. He missed one week from work in the past year because of his depression and anxiety. He had trouble concentrating that slowed him down and caused him to make mistakes. Occasionally, he lost focus and did not finish a job that necessitated him being called to return to the job. If he had a panic attack at work, he locked the door. He sat, breathed, and meditated to try to get himself back together. The Veteran said he could be irritable and sometimes snapped, mainly at co workers and occasionally at supervisors. However, his supervisor really tried to work with him. The Veteran sometimes walked away but, if he did not, he had to go back and apologize for being irritable. As to relationships with others, the Veteran said he had a poor relationship with his wife because of his irritability. She said he snapped more. He had a fair relationship with his three grown children and three grandchildren, but had problems with irritability and withdrawal with them as well. He denied any close friends. The Veteran had four casual friends that he saw once or twice a week when they visited. He might fish three times a year, read, watched television occasionally, and did some yard work. The Veteran went to church about three times a month. He went to high school or college basketball or football games about four or five times a year but the crowd bothered him. On examination, the Veteran was alert, oriented, and attentive, and appeared his stated age. His mood was anxious and depressed and his affect was mood congruent. The Veteran's speech reflected his anxiety. There was some evidence of psychomotor agitation. His though process was logical and coherent and his thought content was devoid of current auditory or visual hallucinations. He denied any current suicidal or homicidal thoughts. The Veteran said that the last time he was physically aggressive with somebody was a couple of months ago. The Veteran's memory was severely impaired for immediate information. The VA examiner wanted to say that this did not appear to be an accurate reflection of his memory ability. The Veteran appeared to lose focus during the evaluation because of some anxiety. His memory for recent and remote events was more intact. He was not able to concentrate well enough to spell world backwards. The Veteran had fair insight into his current condition. The Axis I diagnoses were major depressive disorder, anxiety disorder, nos, and a panic disorder. A GAF score of 53 was assigned. According to the examiner, the Veteran exhibited moderate to considerable symtoms associated with major depressive disorder, anxiety disorder, NOS, and panic disorder. Specifically, the Veteran reported depression with low energy, low motivation, fatigue, decreased feelings of hope and worth, and decline in his appetitie with fluctuating weight. He reported isolation and less interest in activities. The Veteran had problems with concentration, irritability, and sleep. He felt anxious and worried, restless and agitated, and had muscle tension. He had panic attacks during which he felt lightheaded and perspired, and had an increased heart rate. He sometimes hyperventilated, felt he was losing control, and feared he was having a heart attack. He had those twice a week. He had experienced these symptoms for nearly twenty years but believed they were getting worse. He denied periods of remission. Further, the VA examiner noted that, as to activities of daily living such as bathing, the Veteran can go up to three days without a bath. The VA examiner also reported moderate to considerable impairment in terms of the Veteran's his social adaptability and interactions with others and his ability to maintain employment and perform job duties in a reliable, flexible, and efficient manner. Overall, the VA examiner estimated the Veteran's level of disability to be in the moderate to considerable range. Analysis The assigned GAF scores, with one notable exception, have been indicative of moderate disability. On one occasion the Veteran was noted to have a GAF of 49 indicative of serious impairment. Even at that point, specific symptoms equating to those listed as examples in the 70 percent criteria were not reported. The record does not show most of the symptoms listed as examples of those warranting a 70 or 100 percent rating under 38 C.F.R. § 4.140. The Veteran was reported at one point as having difficulty controlling his impulses and reportedly was physically aggressive with someone in 2010 (prior to the August VA examination), but the other symptoms listed in the examples under the 70 percent criteria have not been reported. The Veteran has been noted to have panic attacks, which he reports occur on a basis but this is an example of the symptoms for a 50 percent rating. Evidence does not show that the attacks affected his ability to function independently, appropriately and effectively. Symptoms such as a decline in personal hygiene, spatial disorientation, obsessional rituals which interfere with routine activities, or other symptoms set out for the 70 percent rating are not shown. Although the August 2010 VA examiner reported that the Veteran said he might go up to three days without bathing, the Veteran's treating VA psychiatrist repeatedly reported that the Veteran was adequately groomed. The July 2008 and August 2010 VA examiners, and VA clinicians, have repeatedly described the Veteran as oriented with no evidence of psychotic thought. His speech, as reported during examinations and clinical evaluations, was normal. Although the Veteran testified to having suicidal ideation once a week or several times a month, he told the July 2008 VA examiner that he had no current suicidal ideation, and repeatedly denied to VA clinicians having current suicidal ideation during the appeal period. The weight of the evidence is against a finding that he has suicidal ideation. While during the hearing, the Veteran's representative reported that the Veteran had obsessional rituals, obsessional rituals have not been reported or complained of at any time during the appeal period; and the Veteran did not confirm the representative's report. The recent examiner reported no remission in symptoms, which include depression; but the Veteran has reported elsewhere that he had good and bad days, and has at times reported that he had no symptoms. The August 2010 VA examiner also said that the Veteran's memory was severely impaired for immediate information, but the examiner also doubted this finding. She noted that he lost focus during the evaluation because of some anxiety and that his memory for recent and remote events was more intact and such symptoms are contemplated by the current 50 percent rating. That examiner concluded that there was moderate impairment of social adaptability and moderate to considerable impairment of the ability to maintain employment and perform job duties in a reliable, flexible, and efficient manner. The record also shows some difficulty in family relations, but he has been able to maintain those relationships. He has some friends and although he has reported difficulties in his marriage and only fair relationships with his adult children, he has been able to maintain those relationships for decades. The evidence is, thus, against a finding that he is unable to maintain effective relationships. Or has deficiencies in family relations beyond those contemplated by the 50 percent rating. The Veteran has also reported difficulties on the job, but has remained gainfully employed for many years with the same employer. The 50 percent rating contemplates occupational impairment with reduced reliability and productivity; the record does not show deficiency in the area of work beyond that level. The Veteran's treating psychiatrist did opine in June 2008, that the Veteran had severe impairment in social functioning due to erratic mood swings and difficulty adapting to stressful situations in social environments that effectively rendered him unable to sustain and maintain substantially gainful employment. These conclusions are of little probative value, given that the Veteran has maintained gainful employment throughout the appeal period. The same VA psychiatrist has repeatedly described the Veteran as oriented, found no evidence of unusual thought process, and he found the Veteran's judgment to be good. There is no evidence of deviancies in the areas of thinking or judgment; although the Veteran has occasionally had apparent difficulty with impulse control. He obviously has impairment in the areas of mood; but deficiencies in most of the areas needed for a 70 percent rating have not been demonstrated. In sum, the weight of the evidence is against a finding that the Veteran's symptoms more closely approximate the criteria required for a rating higher than 50 percent. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. 5107(b); 38 C.F.R. § 4.7, 4.21. The Board has also considered whether the Veteran's depression disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2013). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. at 182. Here the Board has considered Mittleider and attributed all potentially service-connected symtoms to his service-connected depression disability before considering if the Veteran is entitled to an extra-schedular rating. If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The manifestations of the Veteran's disability include anxiety, irritability, insomnia, and panic attacks. The rating contemplates all of the occupational and social impairment attributable to the service connected psychiatric disability. The schedule contemplates all of the Veteran's symptoms. Again, the rating schedule is intended to compensate for average impairment in earning capacity and for considerable time lost from work commensurate with the percentage evaluations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. Id.; see also Thun v. Peake, 22 Vet. App. at 111. Entitlement to a total rating based on individual unemployability (TDIU) is potentially an element of all claims for increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). To raise such a claim as part of a claim for increase, there must be evidence of unemployability. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In this case the Veteran has been employed throughout the appeal period, and there is no evidence of unemployability. Thus, any further consideration of the Veteran's claim under Rice is not warranted at this time. The Board finds that at no time since the Veteran filed his most recent claim for an increased rating has the disability on appeal been more disabling than as currently rated under the present decision of the Board. ORDER A rating in excess of 50 percent for depression is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs