Citation Nr: 1331247 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 13-20 727 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, claimed as posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: John R. Worman, Attorney ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran had active service from November 1942 to January 1946. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Throughout the rating period on appeal, the service-connected anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, have been manifested by depressed mood, feelings of anxiety due to intrusive thoughts and flashbacks, avoidance behaviors, irritability, decreased sleep with occasional nightmares, low motivation and energy, concentration problems, feelings of detachment from others, difficulty with intimacy, suspiciousness, and social isolation, productive of functional impairment comparable to occupational and social impairment with reduced reliability and productivity. 2. The most probative evidence of record is in equipoise as to whether, throughout the rating period on appeal, the Veteran's service-connected disabilities alone, considered in combination, rendered him unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no higher, for anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). 2. The criteria for a total disability rating for compensation purposes based on individual unemployability (TDIU) have been met throughout the rating period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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. As entitlement to a TDIU has been granted below, no additional discussion is necessary as to VA's duties to notify and assist with regard to that issue. The Veteran is appealing the initial rating assignment as to his anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified. Because the January 2011 rating decision granted the Veteran's claim of entitlement to service connection for his anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, 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). The Board concludes that VA's duty to assist has also been satisfied with regard to the initial rating assigned. The Veteran's service treatment records are determined to be unavailable in this case. See Memorandum, Formal Finding of the Unavailability of Service Records, dated August 2005. Post service VA and private medical records have been associated with the claims file. The Veteran indicated that he was in receipt of retirement benefits from the Social Security Administration (SSA). The RO requested the Veteran's records from the SSA in March 2012 but received a response from the SSA in March 2012 that the medical records have been destroyed. The RO sent a letter to the Veteran in May 2013 that informed him that his SSA records were not available and requested that he submit any records in his possession. The Veteran did not respond, and the RO made a formal finding in May 2013 that the Veteran's SSA records are not available. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). Concerning this, the RO provided the Veteran an appropriate VA examination in January 2011. The Board finds that the examination was adequate as the examiner discussed the history of the Veteran's anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, conducted a clinical examination of the Veteran, and elicited information from the Veteran concerning the functional aspects of his disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 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). 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 each issue. Factual Background In a September 2009 VA psychiatric consultation report, the Veteran was seen for evaluation and treatment of "depression, sadness, decreased sleep, [and] anhedonia." The Veteran and his son described him as a "loner." He had no friends and there were conflicts without arguments with coworkers, leading the Veteran to change jobs. The Veteran's son related that his father always seemed depressed and irritable and never wanted to go anywhere. He stated that his father was never violent. Currently, the Veteran reported that "I don't feel like doing anything. I mope." He no longer enjoyed watching baseball on television. He had intrusive thoughts of war memories and was easily irritated by his disabled wife. Sometimes, he was ready to give up, but he would never hurt himself. His sleep was poor and he occasionally had nightmares. The Veteran never bonded with other veterans or any veterans groups. He denied excessive anxiety. On mental status examination, the Veteran's affect was subdued and he described his mood as "I don't feel like doing anything." He answered questions with useful information and he had no psychotic thoughts. He had no intent to hurt himself or others. The examiner noted that the Veteran had long standing symptoms of depression, suspiciousness with social isolation, conflicts with coworkers, poor sleep, nightmares, intrusive thoughts of combat, avoidance of reminders, difficulty with intimacy and foreshortened future. The diagnosis was PTSD, and a GAF score of 51 was noted. In a September 2010 VA treatment report, the Veteran's mental status was alert and fully oriented. He reported that currently he did not have PTSD symptoms. In an October 2010 VA treatment report, the Veteran related that there was no significant change in mental and functional status since last visit. The Veteran had stopped taking medications and stated that he did not need it. Clinically, he did not appear anxious or depressed. The Veteran was provided a VA psychiatric examination in January 2011. The VA examiner indicated that the claims file was reviewed. The examiner noted the frequency and severity of the Veteran's depression as 3 to 4 days per week and mild. The Veteran denied anhedonia and suicidal ideation. He reported "pretty good" sleep and fair concentration. There was no evidence of mania or hypomania. As to marital and family relationships, the Veteran stated that he had been married for 67 years describing the union as "very good. We get along very good." He had very close attachment with their four children, three grandchildren and two great grandchildren. However, regarding the degree and quality of social relationships, he stated that "I'm really a loner right now." In his leisure time, he would spend time with family, watch baseball on television, and go out to eat "once in a blue moon." There was no history of suicide attempts, violence/assaultiveness, or issues associated with alcohol or substance abuse. On psychiatric examination, the Veteran was clean, neatly groomed, and appropriately dressed. He exhibited unremarkable psychomotor activity; spontaneous, clear and coherent speech; cooperative, friendly and attentive attitude; normal affect; not "too bad" mood; intact attention; unremarkable thought process and thought content; average intelligence; good impulse control; and normal memory. He was fully oriented, understood the outcome of his behavior and partially understood that he had a problem. He denied sleep impairment, hallucinations, obsessive/ritualistic behavior, panic attacks, suicidal or homicidal thoughts, and episode of violence. He was able to maintain minimum personal hygiene and there was no problem with activities of daily living. The Veteran also reported the PTSD symptoms of intrusive memories, nightmares, flashbacks, avoidance behavior, and detachment. He was found capable of managing financial affairs. As to occupational functioning, the Veteran was currently unemployed and stated that he retired in 1984 because "the place closed down." The diagnoses were anxiety disorder, not otherwise specified; and depressive disorder, not otherwise specified. A GAF score of 65 was assigned for depressive disorder, and 70 was assigned for anxiety disorder. The examiner noted that the Veteran's psychiatric signs and symptoms were transient or mild and that there was decrease in work efficiency and ability to perform occupational tasks only during periods of significant stress. In a March 2012 VA audiology examination report, the VA examiner opined that the Veteran's current hearing loss would at least as likely as not impact physical and sedentary employment; however, it would not make him unemployable. The examiner noted that the Veteran currently had a moderately-severe to profound sensorineural hearing loss in the right ear and moderate to profound sensorineural hearing loss in the left ear. However, the examiner noted that most occupations do not set physical requirements for hearing and only some occupations such as law enforcement, firefighting, and pilots have hearing requirements. The examiner further opined that the Veteran's tinnitus would less likely as not impact physical and sedentary employment as the Veteran reported that the tinnitus was intermittent and was not bothersome. In June 2012, the Veteran underwent a private psychiatric evaluation. The Veteran related that following his military service, he had held numerous jobs, including at a carpet mill, car assembly plant, and other factories. His son stated that his father would move from job to job, had difficulty getting along with others and would get depressed, uncommunicative, often irritable and difficult to deal with. On clinical interview, the Veteran reported living with his wife. He endorsed great difficulty with sleep, at times, due to nightmares. He stated that he would get very anxious and restless. He often had difficulty getting motivated to get out of bed in the morning lacking both motivation and energy. The private psychologist, Dr. A.F., noted that based on a review of the evidence, the January 2011 VA examination did not adequately represent the Veteran's psychological profile, or its overall impact on functioning, with a diagnostic formulation which understated his condition. Dr. F. further noted that psychological disturbances do not typically follow a continuous path but there is, more often than not, a "waxing and waning," some periods of higher frequency or intensity of symptoms, and other periods less so. It was noted that the Veteran's most salient symptomatology included feelings of anxiety due to intrusive thoughts of his time in service, and resultant difficulties in concentration, as well as depressiveness, low energy and motivation, and social isolation. As for employability, Dr. F. opined that the impact of the Veteran's service-connected psychological condition on functionality would significantly limit his ability to function effectively in the work place, particularly in terms of being able to concentrate and persist in tasks for more than minimal periods of time; to take independent action with respect to assigned tasks; to interact effectively with coworkers, the general public, and supervisors. While cognitive abilities were well within normal limits, his affective state substantially reduced his current and potential effectiveness. The diagnoses included generalized anxiety disorder; depressive disorder, not otherwise specified; and PTSD traits, and a GAF score of 50 was listed. Dr. F. indicated that the Veteran's level of occupational and social impairment with regard to all mental diagnoses was best summarized as "[o]ccupational and social impairments with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or school." Dr. F. further indicated that the Veteran's psychiatric symptoms would cause problems with attendance, leaving work early, or interruptions in work tasks at least 3 times per month, and that the Veteran would decompensate frequently in a work place. In July 2012 VA treatment reports, the Veteran's mental status was alert and fully oriented and his appearance was appropriate. His speech was normal and his behavior was appropriate. He lived in his own home with family; he was married. He was independent in activities of daily living. In a June 2012 report, a private vocational consultant indicated that the Veteran's claims file was reviewed. The report stated that the Veteran has a high school education with no additional vocational or educational training. His post-military employment had been in manufacturing in a number of capacities; he had difficulty getting along with others in the work place and had issues with mood stability. It was noted that the Veteran's psychiatric symptoms had been documented as flashbacks, social isolation, depression, anxiety, and intrusive thoughts. The private consultant set forth all relevant VA and private examination findings, and opined as follows: [The Veteran's] most significant impairments, at this time, appear to arise from the impact of his hearing loss combined with his depressive disorder, anxiety and PTSD traits. Based upon the review of medical records in total, it is apparent that [the Veteran] cannot work in a competitive setting and has not been able to for several years. The [V]eteran is totally and permanently precluded from performing work at a substantially gainful activity level due to the severity of his service connected impairments impacting his emotional stability in the workplace. Law and Analysis Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. This appeal originates from a rating decision that granted service connection and assigned the initial rating. Accordingly, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999). Psychiatric Disability Service connection for anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified was granted in the January 2011 rating decision on appeal, and a 10 percent initial disability rating was assigned effective July 16, 2010. The Veteran filed a timely notice of disagreement to the initial rating assigned to his service-connected anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, in January 2012, and perfected his appeal in June 2013. The Veteran's service-connected anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, are evaluated as 10 percent disabling under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Codes 9499-9413. 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 10 percent disability rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. 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. Id. 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.). Id. 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. Id. 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). 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 initial rating. 38 C.F.R. § 4.7 (2012). In reaching this determination, the Board finds it significant that the VA examiner and treatment providers and private psychologist who conducted a comprehensive psychiatric assessment of the Veteran, diagnosed anxiety disorder, depressive disorder and PTSD, and estimated that his GAF score was no less than 50, which, as discussed above, is indicative of 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). DSM-IV at 46-47. Furthermore, the Veteran's symptomatology as evidenced by the record corresponds with, and is compatible with a GAF score in the 50s. The Board acknowledges that a private psychologist listed a GAF score of 50 in June 2012, and technically, a GAF score of 50 borders on serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social, occupational or school functioning, such as no friends, unable to keep a job. Id. However, the Veteran did not show any of these serious symptoms throughout the record and his social and occupation impairment due to the psychiatric symptoms are more consistent with moderate difficulty in social or occupation functioning, as will be discussed below in detail. In short, the Board finds that the Veteran's anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, result in occupational and social impairment with reduced reliability and productivity, due to such symptoms as depressed mood, feelings of anxiety due to intrusive thoughts and flashbacks, avoidance behaviors, irritability, decreased sleep with occasional nightmares, low motivation and energy, concentration problems, feelings of detachment from others, difficulty with intimacy, suspiciousness, and social isolation. While a 50 percent initial rating is warranted, 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 no abnormalities were found with regard to the Veteran's thought processes, speech and communication at any of his VA or private examinations and treatments. The September 2009 VA psychiatric consultation report indicated that the Veteran answered questions with useful information and he had no psychotic thoughts. The January 2011 VA examination reports, specifically, indicated that the Veteran spontaneous, clear, and coherent speech and cooperative, friendly and attentive attitude. He understood the outcome of his behavior and partially understood that he had a problem; his thought process and thought content were unremarkable. At the January 2012 VA treatment, the Veteran's speech was normal and behavior was appropriate. Additionally, the Veteran's appearance, hygiene, and behavior were noted as appropriate throughout the record. Furthermore, while the Board notes that the Veteran reported that he had been very easily irritable, the record is devoid of evidence indicating that the Veteran has had any episodes of violence or aggression. To that effect, the Veteran's son stated in September 2009 that his father was never violent. Lastly, 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. On mental status examinations, the Veteran has been fully oriented, alert, and cooperative. He has exhibited subdued affect; spontaneous, clear and coherent speech; intact attention; and unremarkable thought process and thought content without suicidal or homicidal ideation, hallucinations, delusions, or psychosis. The January 2011 VA examination indicated that the Veteran was able to maintain minimum personal hygiene and there was no problem with activities of daily living. The June 2012 private psychologist noted that the Veteran's cognitive abilities were well within normal limits. Additionally, the July 2012 VA treatment report also noted that the Veteran was independent in activities of daily living. Regarding the Veteran's social relationships with others, he reported having no friends. However, he had been married for over 67 years to his wife and he reporting having very close and loving relationships with his children, grandchildren, and great grandchildren. Although he indicated that he could be irritable and had difficulty with intimacy and that he would rarely go out to eat, overall, he had been able to maintain a fair relationship to the extent that his socially isolative behaviors and emotional problems did not prove to be destructive to his family relationships. During the January 2011 VA examination, the Veteran described his marriage as "very good. We get along very good." Accordingly, while the Veteran has shown significant difficulty establishing social relationships, he has also demonstrated that he is able to establish and maintain relationships, such as his over 67 year long marriage to his wife, and close relationships with his children. With regard to occupational functioning, the Veteran reported that he had worked in manufacturing for many years after service and retired in 1984 or 1989. He has held numerous jobs moving from job to job because he had difficulty getting along with coworkers and would become depressed, uncommunicative, often irritable and difficult to deal with. In this regard, Dr. F. noted that the impact of the Veteran's service-connected psychological condition on functionality would significantly limit his ability to function effectively in the work place, particularly in terms of being able to concentrate and persist in tasks and interact effectively with coworkers, the general public, and supervisors. However, the Veteran was able to maintain employment before 1984 at which time he retired because, he stated, "the place closed down." Based on the foregoing evidence, although significant impairment in occupational functioning is shown, inability to establish and maintain effective relationships, or total occupational impairment due to the service-connected psychiatric disability is not shown. The Board acknowledges that Dr. F. stated that the Veteran's level of occupational and social impairment with regards to all mental diagnoses was best summarized as "[o]ccupational and social impairments with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or school," which is essentially a restatement of part of the criteria for a 70 percent rating. However, although deficiencies in most areas, such as work, family relations, judgment, and thinking are shown, such deficiencies are not due to symptoms of the type and degree of the symptoms, or their effects, contemplated by the criteria for a 70 percent rating. The Board recognizes that as discussed above, the symptoms listed in the 38 C.F.R. § 4.130 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. See Mauerhan, 16 Vet. App. at 442. In this regard, the Board also 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. However, as explained above, nearly none of the serious symptoms listed for the 70 percent rating criteria have been shown in this case. Specifically, 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, inability to establish and maintain effective relationships were not shown. Rather, the Board finds that the Veteran's psychiatric symptomatology affecting the level of his social and occupational functioning level is in the moderate range. There is evidence of difficulty in adapting to stressful circumstances, including work or a work like setting. However, overall, the Veteran's disability picture manifested by depressed mood, feelings of anxiety due to intrusive thoughts and flashbacks, avoidance behaviors, irritability, decreased sleep with occasional nightmares, low motivation and energy, concentration problems, feelings of detachment from others, difficulty with intimacy, suspiciousness, and social isolation more closely approximate the type and degree of symptoms listed in the 50 percent rating criteria. Accordingly, the 50 percent initial rating is the appropriate rating in this case. 38 C.F.R. § 4.7. Staged ratings have been considered. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected psychiatric disability, 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 psychiatric disability. See Fenderson, 12 Vet. App. at 126. The medical evidence of record reflects that the Veteran had similar psychiatric symptoms which appear to have remained relatively stable throughout the rating period on appeal. 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 and depressive disorder. See Thun, 22 Vet. App. at 115. The Veteran's anxiety disorder and depressive disorder are 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 rating assigned herein and he does not have symptoms associated with this disability that have been unaccounted for by the schedular rating assigned herein. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, a comparison of the Veteran's symptoms and functional impairments resulting from his psychiatric disability with the pertinent schedular criteria does not show that his service-connected anxiety disorder and depressive disorder present "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 Veteran's anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified. 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. TDIU TDIU is warranted when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Service connection is in effect for bilateral hearing loss, currently rated as 50 percent disabling; tinnitus, currently rated as 10 percent disabling; and anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, now rated as 50 percent disabling throughout the rating period on appeal. The Veteran's combined disability rating is 70 percent throughout the rating period on appeal. See 38 C.F.R. § 4.25 (2012). As such, the Veteran meets the minimum schedular criteria for TDIU throughout the rating period on appeal. 38 C.F.R. § 4.16(a). The record reflects that the Veteran finished high school, with no additional vocational or educational training. After military discharge, he worked in manufacturing in a number of capacities, to include at a carpet mill, car assembly plant, and other factories. In his VA Form 21-8940, the Veteran repotted that he worked as a machinist full-time from 1972 to 1989 for the same employer but became too disabled to work in 1989 due to his disabilities. The lay evidence of record reflects that the Veteran had difficulty getting along with others in the work place and there were conflicts without arguments with coworkers, leading the Veteran to change jobs. In the June 2012 private psychiatric evaluation report, the Veteran's son stated that his father would move from job to job, had difficulty getting along with others, and would become depressed, uncommunicative, often irritable, and difficult to deal with. In this regard, Dr. F. opined that the impact of the Veteran's service-connected psychological condition on functionality would significantly limit his ability to function effectively in the work place, particularly in terms of being able to concentrate and persist in tasks for more than minimal periods of time; to take independent path with respect to assigned tasks; to interact effectively with coworkers, the general public, and supervisors. Dr. F. further noted that while cognitive abilities were well within normal limits, his affective state substantially reduced his current and potential effectiveness. Furthermore, the March 2012 VA examiner opined that the Veteran's current hearing loss would impact physical and sedentary employment although it would not make him unemployable because most occupations do not set physical requirements for hearing. However, the June 2012 private vocational consultant noted that the Veteran's most significant impairments, at this time, arise from the impact of his hearing loss combined with his depressive disorder, anxiety and PTSD traits, and opined that the Veteran cannot work in a competitive setting and he is totally and permanently precluded from performing work at a substantially gainful activity level due to the severity of his service-connected impairments impacting his emotional stability in the workplace. As noted above, TDIU is warranted if the Veteran is unable to follow a substantially gainful occupation due his service-connected disabilities. 38 C.F.R. § 3.340(a)(1). In this case, applying the doctrine of reasonable doubt, the Board finds that the evidence of record is at least in equipoise as to whether the Veteran is unable to follow a substantially gainful occupation due to his service-connected bilateral hearing loss and anxiety disorder and depressive disorder. To that effect, after a review of the medical records in totality, the private vocational consultant opined that the Veteran was totally and permanently precluded from performing work at a substantially gainful occupation due to his service-connected disabilities. This is consistent with the other medical evidence of record, as well as the Veteran's lay testimony. Accordingly, considering the lay statements, as well as the medical evidence of record regarding the severe functional impairments exhibited by his service-connected bilateral hearing loss and anxiety disorder and depressive disorder, as well as his educational and employment history, the Board finds that the Veteran has been unable to follow a substantially gainful occupation consistent with his education and occupational experience, due to his service-connected disabilities, throughout the rating period on appeal. Accordingly, a TDIU is warranted. Gilbert, 1 Vet. App. at 54. ORDER Entitlement to an initial rating of 50 percent, but no higher, for anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a TDIU, throughout the rating period on appeal, is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs