Citation Nr: 1333885 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 11-01 060 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for mood disorder. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant, Spouse, and Son ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 1953 to January 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision by the Muskogee, Oklahoma, Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2013, the Veteran testified at a video conference hearing before the undersigned Acting Veterans Law Judge. A copy of the transcript of that hearing is of record. The issue on appeal was adequately explained to him and the submission of evidence which he may have overlooked and which would be advantageous to his position was suggested. See 38 C.F.R. § 3.103(c) (2013). The Board remanded the case for additional development in May 2013. This appeal was processed using VA paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's service-connected mood disorder is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, chronic sleep impairment, and mild memory loss; occupational and social impairment with reduced reliability and productivity, deficiencies in most areas, or total occupational and social impairment have not been shown. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for mood disorder have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.16, 4.130, Diagnostic Code 9435 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The Veteran was notified of the duties to assist and of the information and evidence necessary to substantiate his underlying service connection claim by correspondence dated in February 2010. He was provided additional subsequent notice concerning his appeal for an increased initial rating in October 2010. The notice requirements pertinent to the issue on appeal have been met and all identified and authorized records relevant to the matter have been requested or obtained. The available record includes service medical records, VA treatment and examination reports, VA vocational rehabilitation records, and statements and testimony in support of the claim. VA efforts to obtain records of additional private treatment identified by the Veteran by authorization forms VA 21-4142 were unsuccessful. The Veteran was notified in March 2012 and June 2013 of the specific records VA was unable to obtain, of the efforts made to obtain those records, of the further action to be taken by VA with respect to the claim, and that he was ultimately responsible for providing the evidence. The development requested on remand in May 2013 has been substantially completed. Although the Veteran provided additional forms VA 21-4142 in June 2013, the identified treatment was related to a disability not currently on appeal and he did not indicate the records included any evidence pertinent to his present appeal. The Board finds there is no evidence of any additional existing pertinent records. Further attempts to obtain additional evidence would be futile. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. VA medical opinions obtained in this case are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to adjudicate the claim would not cause any prejudice to the appellant. Increased Rating - Pertinent Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran's disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). The United States Court of Appeals for Veterans Claims (Court) has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2013). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2013). VA regulations provide that the effect of a change of diagnosis including keeping in mind the repercussion upon a current rating of service connection when change is made of a previously assigned diagnosis or etiology. It is noted that the aim should be the reconciliation and continuance of the diagnosis or etiology upon which service connection for the disability had been granted. The relevant principle enunciated in 38 C.F.R. § 4.125, entitled "Diagnosis of mental disorders," should have careful attention in this connection. When any change in evaluation is to be made, the rating agency should assure itself that there has been an actual change in the conditions, for better or worse, and not merely a difference in thoroughness of the examination or in use of descriptive terms. This will not, of course, preclude the correction of erroneous ratings, nor will it preclude assignment of a rating in conformity with 38 C.F.R. § 4.7. 38 C.F.R. § 4.13 (2013). General Rating Formula for Mental Disorders: Rating 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 100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships 70 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 50 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) 30 38 C.F.R. § 4.130, Diagnostic Code 9435 (2013). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Court has held that global assessment of functioning (GAF) scale scores reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.) (DSM-IV), p. 32). Global Assessment of Functioning Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. 61 - 70 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. 60 ?- 51 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). 50 - 41 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). American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (1994) (DSM-IV). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Court has also held that in determining the level of impairment under 38 C.F.R. § 4.130 VA is not restricted to the symptoms provided in the diagnostic code. Ratings are to consider all symptoms of the disability that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. See Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Factual Background The evidence of record shows the Veteran raised a claim for an acquired psychiatric disorder secondary to his service-connected bilateral hearing loss and tinnitus disabilities in February 2010. Service connection was established for mood disorder in a September 2010 rating decision and a 30 percent disability rating was assigned effective from February 3, 2010. In his September 2010 notice of disagreement, the Veteran asserted that a 50 percent rating was warranted because his symptoms when he was not taking medication met the requirements for that rating. In testimony provided in March 2013 the Veteran, his spouse, and his son asserted that his psychiatric symptoms had worsened since his last VA examination in 2011. The Veteran testified that he had experienced problems with his memory and his spouse noted that a diagnosis of Alzheimer's dementia had been provided. She further noted that the Veteran's symptoms included frustration and aggravation, particularly when he had trouble understanding people. The Veteran and his spouse reported that he no longer enjoyed participating in past hobbies, such as hunting or fishing, and that he was socially isolated. The Veteran's son testified that his father mainly sat on the patio listening to the radio and stated that he thought he had become more withdrawn over the past two years. The pertinent VA treatment records show that in February 2010 the Veteran complained of almost daily depression for the past two years. He stated he had feelings of helplessness and worthlessness, frequently, and anhedonia. He also stated that during bouts of depression he would withdraw to his home. He reported a 15 pound weight loss over the past year with decreased appetite. He denied suicidal and homicidal ideation and denied any previous suicide attempts. He denied any audio or visual hallucination and denied delusions. He admitted to flashbacks from Korea and described flashing back to guard duty and hearing enemy soldiers crawling around in the grass at night. It was noted these flashbacks affected his sleep. The examiner noted the Veteran had begun taking Zoloft earlier that month and that he was informed that the medication may take two to four weeks to start seeing effects. The examiner stated that the Veteran presented with a depressed mood and flat affect, but that he was dressed and well-groomed. The Veteran's speech was coherent and goal oriented and his thoughts were organized. There was no evidence of psychosis. The diagnoses included recurrent major depressive disorder and late-onset dysthymic disorder. Additional treatment records dated in February 2010 noted the Veteran reported that he had been depressed for many years and that his depressive episodes lasted more than two weeks with hopelessness, helplessness, anhedonia, decreased concentration, decreased appetite, and insomnia. He stated he had never had suicidal ideation and denied any history of suicidal behavior which he attributed, in part, to his involvement with military funeral services and being an honor guard. He denied any history hypomania or mania. He reported he drank a small glass of wine daily. The examiner recommended that he avoid alcohol completely because it may cause depression, anxiety, insomnia, seizure, withdrawal, and other medical complications. It was noted he was dressed casually and well-groomed. His mood was depressed mood, but his speech was coherent and goal directed. His thoughts were organized and he denied any suicidal or homicidal ideation. There was no evidence of psychosis. The diagnoses included recurrent major depressive disorder and dysthymic disorder. In March 2010, the Veteran stated he was very happy with the sertraline and that he was able to sleep and better able to tolerate his daughter-in-law now. The examiner noted sleep was improved and his anxiety was decreased. An April 2010 report noted he stated he was feeling less depressed, but that he still had agoraphobia. The examiner noted he was in no apparent distress. Insight and judgment were intact. He denied any intent to harm himself or others. His thoughts were organized and coherent. It was noted sleep was improved. The diagnosis was major depressive disorder. A May 2010 report noted he was able to sleep for nine hours and that his major depressive disorder was improving. A June 2010 treatment report noted the Veteran complained of depression related to trouble performing his volunteer job at funerals for deceased veterans because his tinnitus and decreased hearing cause. He also stated he was depressed because he had tinnitus since he got out of the service in 1955 that had affected his anxiety level and sleep for the past 50 years. The sleep deprivation was described as chronic and with the tinnitus he had become depressed. He was both anxious and depressed and had flashbacks of being on guard and being in Korea under severe weather conditions. The examiner noted he was alert and oriented times four, but was depressed, stoic, anxious, and tearful at times. His thoughts were organized and he denied any intent to harm himself or others. He stated he saw shadows peripherally at times due to depression. His mood was depressed/anxious and his affect restricted. Insight, judgment, and memory were intact. The diagnoses included major depressive disorder secondary to his service-connected tinnitus and hearing impairment, sleep disorder secondary to tinnitus, and anxiety disorder. On VA examination in July 2010 the Veteran reported he had chronic tinnitus for over 50 years which impaired his ability to perform his duties as the commander for an honor guard providing military funerals. The Veteran stated he had been doing funeral honor guard work since 2004 and worked between 150 and 200 funerals a year. He stated that performing these funerals was very important to him and said that because of his hearing loss it was sometimes difficult for him to perform appropriately. He stated he had experienced trouble sleeping, but that with medication he had been able to sleep better. He reported he had been a salesman most of his working life and that his last job was as a transit driver. He also stated that he and his spouse had owned their own beauty shop, but that they had to quit when his spouse developed breast cancer a number of years earlier. He indicated his symptoms affected his total daily functioning which resulted in mild impairment socially and occupationally. He stated he did not have trouble sleeping and did not have a history of violent behavior. It was noted he did not indicate a history of suicidal behavior. He reported he had not received psychotherapy for his mental condition within the past year and had not been hospitalized for psychiatric reasons. His unemployment was not believed to be due to the effects primarily of a mental condition. The examiner noted that orientation was within normal limits and appearance and hygiene were appropriate. His behavior was appropriate and his affect and mood were normal. Communication, speech, and concentration were within normal limits. There was no evidence of panic attacks, suspiciousness, delusions, hallucinations, obsessive - compulsive behavior, or suicidal or homicidal ideation. His thought processes were appropriate and he was able to understand directions. He did not appear to be confused and his judgment was not impaired. Abstract thinking was considered normal and memory was within normal limits. Overall, it was noted he presented with a fairly serious demeanor. The diagnoses included mood disorder secondary to service-connected hearing loss/tinnitus. A GAF score of 61 - 65 was provided. The severity of his depression was considered mild and had responded positively to medication. It was noted he did not have difficulty performing activities of daily living and that he was able to establish and maintain effective work/school and social relationships. The best description of his current psychiatric impairment was psychiatric symptoms controlled by continuous medication. He had no difficulty understanding commands and did not appear to pose any threat of danger or injury to self or others. VA treatment records dated in August 2010 noted he was humorous and that with medication his sleep was improved. A November 2010 mental status examination noted he was awake, alert, and friendly and cooperative with a good sense of humor. He was neatly groomed and casually dressed. He was oriented to month, day, location, and year, but missed the correct date. His speech was normal in pace and prosody, his mood was euthymic, and his affect was bright. His thought processes were linear, but he occasionally lost his train of thought and required cuing. There was no evidence of perception or delusions. He had poor recall for remote and recent events. Intelligence and abstraction were good and he denied suicidal and homicidal ideation. The diagnosis was recurrent major depressive disorder and a GAF score of 55 was assigned. It was noted that the Veteran could benefit from psychological testing to determine the nature and extent of his reported memory problems. Records dated in December 2010 noted he reported he was "doing well at this time" after undergoing a pacemaker placement one week earlier with improvement both physically and emotionally. He stated his forgetfulness had decreased since the procedure. The examiner noted he was alert and oriented times four. His mood was euthymic and his affect was within normal limits. His speech was clear and his thoughts were goal directed. Suicidal ideation, homicidal ideation, delusions, and hallucinations were denied. Concentration, abstraction, intelligence, comprehension, memory, insight, and judgment were good. The diagnosis was mild recurrent major depressive disorder and a current GAF score of 60 was provided. A January 2011 mental health note shows the Veteran presented alert and oriented times four. His mood was euthymic and his affect and psychomotor activity were within normal limits. His speech was clear and his thoughts were goal directed. Current suicidal ideation, homicidal ideation, delusions, and hallucinations were denied. Concentration was fair and abstraction, intelligence, comprehension, insight, and judgment were good. Memory was good for remote information, but poor for recent and new information. The diagnoses included mild recurrent major depressive disorder and mild cognitive disorder. A GAF score of 55 was provided. The treatment plan includes a referral to neuropsychology for an evaluation to rule in/out dementia. A February 2011 neuropsychology note shows the Veteran reported that his memory was leaving him. He noted he wrote down appointments and had difficulty remembering names of new people and places, but denied significant difficulties tracking date or time and denied significant attention or problems solving difficulties. He reported occasional irritability and "grouchiness" with "ups and downs." He denied suicidal ideation intent or plan and stated that more recently his mood had been relatively good. He denied sleep disturbance, personality change, and hallucinations/delusions. The examiner noted the Veteran could hear and understand with his hearing aide and that his conversational speech was fluent and goal directed generally. He had occasional word finding difficulties in running speech with circumlocutions and verbalizations. His mood was euthymic and appropriate to the testing situation. Tests administered included the Clinical Interview Wechsler Adult Intelligence Scale-IV (WAIS-IV selected subtests only), Wechsler Memory Scales-IV (WMS-IV selected subtests only), Trailmaking Tests A&B (TMTA B), Phonemic and Semantic Fluency, Geriatric Depression Scale-Short form (GDS-SF), Dementia Severity Rating Scale (DSRS), Frontal Behavior Interview (FBI), Lawton and Brody L scales Luria motor programming tasks Praxis screening Grip Strength, Hopkins Verbal Learning Test-Revised (Form 1 HVLT-R), and Boston Naming Test (BNT). On the WMS-IV memory for stories was mildly impaired immediately after presentation and moderately impaired after a 25 minute delay with minimal details recalled despite cueing. Recognition memory was severely impaired and memory for visual figures was severely impaired immediately after presentation with gross distortion of figural elements. The examiner found the overall pattern of performance suggested a mild global cognitive impairment including both cortical (memory consolidation difficulties anomia visuospatial disturbances) and fronto-subcortical (variable information processing speed relatively more problems with phonemic than semantic fluency) dysfunction. It was noted that depression seemed minimal at that time and that it was believed the findings reflected a relatively mild mixed vascular and Alzheimer's dementia. Treatment records dated in March 2011 noted the Veteran was doing "quite well on the depression medication" and that he "denied any problems with sleep, appetite, depressed/sad mood, suicide/homicide ideation, and anhedonia." The examiner noted the Veteran was alert and oriented times four. His mood was euthymic and his affect was within normal limits. The Veteran's speech was clear and his thoughts were goal directed. Suicidal ideation, homicidal ideation, delusions, and hallucinations were denied. Concentration, abstraction, intelligence, comprehension, memory, insight, and judgment were good. The diagnosis was depression and a current GAF score of 60 was provided. On VA examination in September 2011 the Veteran reported symptoms of memory problems and occasional insomnia which were mild in severity. He stated the symptoms affected his total daily functioning and resulted in memory problems and reported trouble sleeping for several years. The examiner noted orientation was within normal limits and appearance and hygiene were appropriate. Affect and mood were considered normal and communication, speech, and concentration were within normal limits. There was no evidence of panic attacks, suspiciousness, delusions, hallucinations, obsessive - compulsive behavior, or suicidal or homicidal ideation. His thought processes were appropriate and he was able to understand directions. He did not have slowness of thought and did not appear confused. Judgment was not impaired and abstract thinking was normal. His memory was impaired and the degree was mild with forgetting names, directions, and recent events. He was neatly dressed in casual clothing with good hygiene. There was no overt evidence of depression or anxiety. The diagnosis was depressive disorder and a GAF score of 65 was provided. The examiner found the Veteran's symptoms were inconsistent with a diagnosis of posttraumatic stress disorder and that due to minimal evidence supporting a diagnosis of recurrent depression the reported depression symptoms were more consistent with a chronic adjustment disorder. It was noted that mentally he did not have difficulty performing activities of daily living and that the best description of his current psychiatric impairment was psychiatric symptoms controlled by continuous medication. He was able to establish and maintain effective work/school and social relationships; was able to maintain effective family role functioning; had no difficulty with recreation or leisurely pursuits; had no difficulty with physical health; and had no difficulty understanding commands. His condition was found to be stable on current medication with minimal impairment. VA treatment records dated in February 2012 noted the Veteran still reported depression symptoms from time to time and reported feeling worried about things without identification of a particular issue that prompted anxiety. He denied suicidal or homicidal ideation, intent, or plan and denied auditory or visual hallucinations. There was no evidence of other problems with mood. The examiner found the Veteran had a mild to moderate global cognitive impairment and noted that since his last evaluation there had been mild declines in processing speed, semantic fluency, and adaptive functioning. It was noted the most likely explanation for his profile and changes over time was mild Alzheimer's disease. A February 2012 mental health note shows the Veteran reported he had stopped performing honor guard activities due to problems with his spouse's mobility. The examiner found there were no significant changes in mental status. The diagnoses included major depressive disorder, in remission, and early dementia. A GAF score of 55 was assigned. A July 2013 VA examiner found the Veteran met the DSM-IV criteria for mood disorder and dementia of the Alzheimer's type. It was noted the Veteran maintained that he had intermittent depressed mood, occasional anxiety and worry, occasional passive thoughts of death without intent, and significant memory impairment and disturbance in executive functioning. His mood disorder symptoms appeared to be minimally related to changes in impairment in functional status and the Veteran's quality of life, and his dementia of the Alzheimer's type appeared to be significantly related to changes in impairment in functional status and quality of life. Memory impairment and disturbance in executive functioning interfered with his ability to comprehend instructions, recall simple information, limited his daily activities to yard work, and severely limited his vehicle driving. The examiner's prognosis for improvement of psychiatric condition and impairments in functional status was fair for mood disorder and poor for dementia of the Alzheimer's type. It was noted that his mood disorder had not deteriorated since his VA examination in 2010, but that his memory had significantly worsened since his neuropsychological evaluation in 2011. The examiner found the Veteran's dementia of the Alzheimer's type was not part and parcel of the service-connected mood disorder and that it was a separate disorder not associated with the mood disorder. The symptoms associated with the service-connected mood disorder were limited to intermittent depressed mood, occasional anxiety and worry, and occasional passive thoughts of death without intent. The nonservice-connected dementia of the Alzheimer's type involved memory impairment and disturbance of executive functioning. A GAF score associated with the service-connected mood disorder of 65 was assigned and was described as resulted in only mild social and occupational impairment. Analysis Based upon the evidence of record, the Board finds the Veteran's service-connected mood disorder is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, chronic sleep impairment, and mild memory loss. Although the Veteran asserted that a 50 percent rating was warranted based upon his reports of symptom manifestation without medication, the Board finds there are no provisions in VA law for a higher rating based upon symptoms that may worsen or become manifest in the absence of treatment. The evidence in this case indicates that the Veteran's psychiatric disorder symptoms initially improved with medication during the course of this appeal and that subsequently he developed symptoms that were attributed to an unrelated, nonservice-connected cognitive disorder with a diagnosis of dementia of the Alzheimer's type. The July 2013 VA examiner's opinion is persuasive that the facts in this case do not represent a change in diagnosis nor merely a difference in the thoroughness of examinations or the use of descriptive terms in medical reports. The Board notes that medical reports dated in July 2010 and December 2010 indicate no more than mild depression or mood disorder with assigned GAF scores of 61-65 and 60 indicative of mild or, at most, the lower level of moderate impairment. A January 2011 report provided diagnoses of mild depression and mild cognitive disorder and reports dated in February 2011 and September 2011 found minimal evidence of depression. A February 2012 report found the Veteran's depression was in remission. Although the records show the Veteran reported increased memory problems beginning in approximately August 2010, the subsequent reports attribute these increased symptoms to a nonservice-connected cognitive disorder described as dementia of the Alzheimer's type. The evidence does not demonstrate that at any time over the course of this appeal the Veteran's service-connected mood disorder has been manifest by an occupational and social impairment with reduced reliability and productivity nor with deficiencies in most areas. Nor is it shown to be a total occupational and social impairment. Although a flattened affect was noted in February 2010, the subsequent evidence indicates improvement in mood and affect with medication. The single notation of a flatten affect is found to have been representative of an acute rather than chronic manifestation of a psychiatric disability. A February 2011 examiner also noted the Veteran had occasional word finding difficulties in running speech with circumlocutions and verbalizations, but found that his depression seemed minimal at that time and that the findings were attributable to a relatively mild mixed vascular and Alzheimer's dementia. There is no evidence of additional symptoms such as circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships related to the service-connected mood disorder. Therefore, the Board finds an initial rating in excess or 30 percent is not warranted. The Board further finds there is no evidence of any unusual or exceptional circumstances related to the service-connected mood disorder that would take the Veteran's case outside the norm so as to warrant an extraschedular rating. The service-connected mood disorder is adequately rated under the available schedular criteria and the objective findings of impairment are clearly documented. The Court in Thun v. Peake, 22 Vet. App. 111 (2008), has established a three-step inquiry for determining whether a Veteran is entitled to extraschedular rating consideration. First, determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors, such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Although the evidence indicates the Veteran not working, the Board finds the overall evidence of record in this case is not indicative of a marked interference with employment as a result of the service-connected disability. The medical evidence demonstrates his service-connected psychiatric disability to be mild or no more than moderate at any point over the course of the appeal. In fact, a July 2010 VA examiner found his unemployment was not believed to be due to the effects primarily of a mental condition. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the claim. ORDER Entitlement to an initial disability rating in excess of 30 percent for mood disorder is denied. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs