Citation Nr: 1334032 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 12-25 572 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a rating in excess of 70 percent for depression. REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD Sarah Plotnick, Associate Counsel INTRODUCTION The Veteran had active duty service from October 1986 to September 1990. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied a rating in excess of 50 percent for depression. During the course of the appeal, in an August 2012 rating decision, a 70 percent rating for depression was granted, effective October 21, 2009, the date VA received the Veteran's claim for an increased rating. As the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Therefore, as the Veteran was not awarded the maximum rating for depression, the issue remains in appellate status and has been characterized as shown on the first page of this decision. The Board notes that the issues of entitlement to service connection for a low back disability and residuals of an injury to the left leg were previously on appeal before the Board. In May 2012, the Board remanded the issues for further development. Following the completion of such development, the agency of original jurisdiction (AOJ) issued a supplemental statement of the case in July 2013; however, prior to the recertification of the appeal to the Board, the Veteran indicated in an August 2013 statement that she wished to withdraw her appeal as to both issues. Therefore, as such issues have been withdrawn, they are not properly before the Board. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). In May 2012, the Board also remanded the issue of entitlement to an increased rating for depression for the issuance of a statement of the case in accordance with Manlincon v. West, 12 Vet. App. 238 (1999). Such was accomplished in August 2012 and the Veteran perfected her appeal in September 2012. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the Virtual VA claims file reveals additional VA treatment records not contained in the paper claims file. While such records, as well as a complete copy of the Veteran's Social Security Administration (SSA) records and a December 2012 denial letter from VA's office of Vocational Rehabilitation & Employment were added to the record after the issuance of the August 2012 statement of the case. However, in statements dated in June 2012 and September 2012, the Veteran indicated that she would waive AOJ consideration of any newly received evidence. 38 C.F.R. § 20.1304(c) (2013). Therefore, the Board may properly consider the evidence received since the issuance of the August 2012 statement of the case. FINDING OF FACT For the entire appeal period, the Veteran's service-connected depression has been productive of occupational and social impairment, with deficiencies in most areas, but does not result in total occupational and social impairment. CONCLUSION OF LAW The criteria for a rating in excess of 70 percent for depression have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9434 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the 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. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all elements of a claim, including the degree and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a letter dated in November 2009, sent prior to the initial unfavorable rating decision issued in June 2010, advised the Veteran of the evidence and information necessary to substantiate her claim for an increased rating for depression as well as her and VA's respective responsibilities in obtaining such evidence and information. Additionally, the letter advised her of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. With regard to the duty to assist, all pertinent, identified medical records have been obtained and considered, including VA treatment records dated from 2008 to 2013, private medical records, SSA records, and a December 2012 letter from VA's office of Vocational Rehabilitation & Employment. The Board notes that the record includes private treatment records from Dr. E.T., dated between September 2009 and November 2009; however, these records are entirely illegible. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was afforded a VA examination in conjunction with the claim on appeal in April 2010. Neither the Veteran nor her representative has alleged that such is inadequate for rating purposes. Moreover, the Board finds that the examination is adequate in order to evaluate the Veteran's service-connected depression as it includes an interview with the Veteran, a review of the record, and a full mental status examination, addressing the relevant rating criteria. The Board acknowledges that such VA examination was conducted more than three years ago; however, the remainder of the record adequately reveals the current state of the Veteran's disability. Specifically, as will be described in detail below, there is additional medical evidence, including VA treatment records dated through July 2013, that adequately addresses the level of impairment of her depression since the last examination. Allday v. Brown, 7 Vet. App. 517, 526 (1995). Moreover, the Veteran has not alleged that her depression has increased in severity since the April 2010 VA examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (finding that mere passage of time not a basis for requiring of new examination). Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. As noted in the Introduction, in May 2012, the Board remanded this issue for the issuance of a statement of the case in accordance with Manlincon v. West, 12 Vet. App. 238 (1999). Such was accomplished in August 2012 and the Veteran perfected her appeal in September 2012. Therefore, the AOJ fully complied with the May 2012 Board remand orders. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). For the foregoing reasons, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage in this case. As such, the Veteran will not be prejudiced by a decision on the merits of her claim. II. Analysis By way of background, a November 2008 rating decision granted service connection for depression and assigned an initial 50 percent evaluation, effective May 13, 2008. The Veteran did not enter a notice of disagreement with respect to the initially assigned rating and no new and material evidence was associated with the claims file within one year of the rating decision. 38 C.F.R. § 3.156(b) (when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). In this regard, while additional VA treatment records were associated with the claims file within one year of the November 2008 rating decision, this additional evidence was not new and material as it showed that the Veteran had the same depressive symptoms as were considered previously by the RO. Thereafter, VA received the Veteran's current claim on October 21, 2009, for an increased rating for her depression. The RO then issued a rating decision on June 15, 2010, continuing the Veteran's 50 percent rating for depression. The Veteran submitted a notice of disagreement in September 2010. The RO subsequently issued another rating decision in August 2012, which granted a 70 percent rating, effective October 21, 2009, the date of the Veteran's claim for an increased rating, and the Veteran perfected her appeal. The Veteran is service-connected for depression, which is currently evaluated as 70 percent disabling, effective October 21, 2009. She claims that her disability is more severe than what is reflected under a 70 percent rating and that she is entitled to a higher rating. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The 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 ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. The Veteran's depression is currently evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9434, which pertains to depression. Under such regulations, ratings are assigned according to the manifestation of particular symptoms. 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). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, 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 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Under the General Rating Formula, the criteria for a 70 percent rating are: 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. The criteria for a 100 percent rating are: 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. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the DSM-IV, GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. There is no question that the GAF score and interpretations of the score are important considerations in evaluating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In addition to her depression, the Veteran also has diagnoses of posttraumatic stress disorder (PTSD); a mood disorder, not otherwise specified; and a personality disorder, not otherwise specified, as demonstrated by June 2012 treatment notes from Dr. W.A., the Veteran's private psychologist. The Court has held that, when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the Veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181 (1998). Therefore, if the Veteran's psychiatric symptoms are not clearly separated, the Board will attribute all such symptoms to her service-connected depression. Following a review of the relevant evidence of record, which includes VA treatment records dated from October 2008 to July 2013, the Veteran's own statements and the Veteran's representative's statements, October 2008 and April 2010 VA examination reports, SSA records, and private treatment records, the Board concludes that the Veteran is not entitled to a rating in excess of 70 percent for depression. In this regard, the Board finds that, for the entire appeal period, such disability is manifested by deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran has not shown more severe manifestations that more nearly approximate total occupational and social impairment. In this regard, the Board finds that such symptomatology, to include anxiety, depressed mood, anger, and panic attacks, are contemplated in her current 70 percent rating. As indicated previously, a 100 percent rating is warranted where 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. In this regard, there is no evidence that the Veteran has gross impairment in thought processes or communication. In this regard, while there is some impairment in such area, it is not shown to be gross impairment. In this regard, the Veteran's thought processes generally have been described as "logical, relevant, [and] goal directed." See, e.g., February 27, 2012, VA treatment notes. However, at an April 2010 VA examination, the Veteran's thought process was described as "rambling" and involved "preoccupation with one or two topics." The examiner noted that the "Veteran perceives that wherever she goes, she is sexually harassed, and that 'it will always be there.'" The examiner further opined that the "Veteran may be exhibiting poor reality orientation, as she perceived sexual harassment 'everywhere' and all the time." Additionally, the Veteran's thought processes have been described as tangential at times. For example, August 2009 VA treatment records show that the Veteran's thought processes were "tangential frequently," but also generally logical. In June 2009, her thought processes were described as "rambling and unfocused;" in April 2009, they were described as "tangential, and somewhat paranoid;" and in December 2008, they were "generally logical and goal-directed however, rambling, tangential, and disjointed at times." Dr. W.A.'s August 2010 report notes that the Veteran reported "[c]ognitive difficulties, including the diminished ability to think and indecisiveness." In December 2008, VA treatment notes reflect that the Veteran's insight and judgment were "fair to poor," and Dr. W.A.'s August 2010 report noted that her "[j]udgment and insight...appeared to fall below normal limits." While the Veteran has shown some deficiencies in thought processes, such have more frequently been described as adequate and her judgment for social conventions as intact. Additionally, although the Veteran's thought processes have sometimes been described as tangential and rambling, she has had no diagnosis of or treatment for a formal thought disorder. Therefore, while there is some impairment related to the Veteran's thought processes, such is more nearly represented by the level of severity described under a 50 percent rating, which includes symptoms such as "impaired judgment" and "impaired abstract thinking," or under a 70 percent rating, which includes symptoms such as "speech intermittently illogical, obscure, or irrelevant." Therefore, based on the aforementioned findings, the Board finds that, at no point during the appeal period, has the Veteran exhibited signs of gross impairment in thought processes or communication. Additionally, there is no evidence of persistent delusions or hallucinations. The medical evidence of record does not show any evidence of such symptoms, and the Veteran has not contended that she has experienced these symptoms. The evidence also fails to demonstrate that the Veteran has exhibited grossly inappropriate behavior. While an August 2010 private treatment report noted that the Veteran had difficulties with impulse and anger control, her impulse control has also been frequently described in VA treatment records as intact. Additionally, although the Veteran has experienced "angry outbursts,", as demonstrated in a December 2011 VA treatment record where she "tore up her room," there has been no evidence that the Veteran has exhibited grossly inappropriate behavior. Her level of impairment in this regard is more nearly approximated by the level of severity represented by a 70 percent rating, which includes a symptom for "impaired impulse control (such as unprovoked irritability with periods of violence)." Moreover, there is no evidence that the Veteran is in persistent danger of hurting herself or others. The Veteran consistently has reported that she has no suicidal or homicidal ideation. In August 2010, the Veteran's private psychologist, Dr. W.A., noted that the Veteran previously had suicidal ideation, which was "markedly apparent in 2007." Dr. W.A. further noted that the Veteran had "[r]ecurrent thoughts of death, including suicidal ideation," but that the Veteran last considered suicide in "early 2008." As to the Veteran's suicidal ideation or plan, "[s]pecific means, plans, time frames, and immediate intent were denied." In that same report, Dr. W.A. noted that "[h]omicdal ideation was [] apparent." Dr. W.A. further reported that "[the Veteran] has homicidal tendencies and is unable to maintain a normal standard of living," A June 2012 examination report by Dr. W.A. also noted that "[h]omicdal ideation was [] apparent." However, the June 2012 report also states that "[s]uicidality and homicidality were not apparent." This June 2012 finding of homicidal ideation is entitled to limited probative value because the report is internally inconsistent. However, even finding that the Veteran has homicidal ideation, a 100 percent disability rating contemplates a Veteran in persistent danger of hurting oneself or others, which is not shown here. The evidence likewise fails to show that the Veteran has an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). The evidence of record shows that the Veteran consistently has been noted as well-groomed and casually but appropriately dressed. Further, the Veteran has not contended that she has any difficulties performing activities of daily living as a result of her depression. The Veteran has also not been noted to have experienced disorientation to time or place. The medical evidence of record shows that she has been intact to person, time, and place. Further, the Veteran has not contended that she has experienced any disorientation to time or place. Finally, there has been no evidence that the Veteran has experienced memory loss for names of close relatives, her own occupation, or her own name. Her memory has been described as intact. Dr. W.A.'s August 2010 evaluation report stated: [The Veteran's] immediate memory abilities, as evidenced by her providing the correct spelling of the word 'world' in both the forward and the backwards directions, as a measure of auditory working memory, appeared to fall within normal limits. [Her] memory for recent events, as evidenced by her recall of her previous evening meal, appeared to fall within normal limits, as did her memory for recent past events, assessed via her recall of her activities during the weekend preceding the evaluation. Remote memory, assessed via her recall of her birthplace, appeared to be intact. A private chiropractor, Dr. P.Y., submitted a consultation report from April 2011, stating that the Veteran has PTSD symptoms, "which include, but are not limited to insomnia, sleep deprivation, anxiety, anger, rage, isolation, memory loss, hyper vigilance, and memory loss [sic]." However, Dr. P.Y. did not conduct any diagnostic tests or describe the extent to which the Veteran suffers from memory loss. Under the rating criteria, a 50 percent rating contemplates "impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks)." A 100 percent rating is justified by much more severe symptomatology, to include memory loss of names of close relatives, her occupation, or her own name, which has not been demonstrated at any point during the appeal period. The evidence shows that the Veteran has not demonstrated the symptoms listed under the 100 percent rating criteria. However, the Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the 100 percent rating criteria, such as flashbacks, diminished interest, hypervigilance, and a history of substance abuse. SeeMauerhan, supra. In this regard, an August 2010 examination report by Dr. W.A. noted that the Veteran had a history of substance abuse. However, she reported that she stopped drinking in 2008. The Veteran stated that she experienced flashbacks, particularly at night, and had recurrent nightmares and night sweats. The Veteran experienced cognitive and physiological responses to trauma cues in reaction to unanticipated loud noises. She also reported insomnia, hypervigilance, and an exaggerated startle response. Dr. W.A. noted: A pattern of dissociative memory processes was apparent in her accounts of the rape . . . . A pattern of markedly diminished interest and participation in significant, and particularly social, activities relative to her behavior prior to her military service was described. Feelings of detachment or estrangement, associated with her intense need for self-protection, were reported. A restricted range of affect was described. In April 2010, the Veteran underwent a VA psychiatric examination. The examiner noted that the Veteran's symptoms included "[d]epressed mood, social withdrawal, decreased appetite, irritability, amotivation, problems with focusing and concentration; depressive symptoms occur daily, usually in the later part of the day, severe in nature." Her affect was described as normal. The Board has also considered the Veteran's SSA records. While SSA records reflect that the Veteran has been rendered unemployable, this decision was not based on depression alone. In determining that the Veteran was unemployable, SSA also considered her degenerative joint disease and asthma. Likewise, the Veteran was denied VA vocational rehabilitation and employment services in December 2012 on the basis of her service-connected depression and nonservice-connected back condition and PTSD. It was noted that such conditions result in functional limitations that significantly impede her ability to obtain and maintain employment. Specifically, the Veteran's limitations were noted to include physical abilities beyond the sedentary physical demand classification, and some difficulties with interpersonal relationships due to depression. Therefore, while VA's office of Vocational Rehabilitation & Employment determined that the Veteran was not eligible for services, such decision was based on physical disabilities in addition to her service-connected psychiatric disability. Moreover, when considering the Veteran's symptoms in total, the Board finds that they do not result in total occupational and social impairment. With respect to occupational impairment, as noted previously, while the Veteran has been determined to be unable to work by SSA and VA's office of Vocational Rehabilitation & Employment, such determinations were based on physical disabilities in addition to the Veteran's depression. The Board acknowledges that the Veteran has been granted a total disability rating on the basis of unemployability (TDIU) due to her depression. However, such information pertains to a determination of employability which is separate and distinct from the schedular evaluation of the Veteran's depression under the applicable rating criteria. In this regard, while her depression may render her unemployable, resulting in total occupational impairment, the evidence fails to demonstrate total social impairment. In this regard, in 2009 VA records, it was noted that the Veteran was doing volunteer work. Additionally, in a December 2011 VA treatment note, it was reported that the Veteran had long standing anger problems that damage her relationships and was struggling with friendships and relationships; however, it was also noted that she had a new relationship that she wanted to protect. In January 2012, it was again observed that the Veteran reported continued problems with relationships, but she was currently dating her landlady. Finally, in his June 2012 evaluation, Dr. W.A. noted that the Veteran experienced relationship problems; however, he also indicated that she had been involved in a long-distance romantic relationship for nearly one year. Moreover, he observed that the Veteran was, in fact, in intense need of social contact. (Emphasis added). Therefore, while the Veteran's psychiatric symptomatology impairs her socially, which is contemplated in her current 70 percent rating, such does not result in total social impairment as the Veteran is able to be in relationships and had, in fact, maintained a relationship for over a year. Moreover, Dr. W.A. has indicated that the Veteran, in fact, is in need of social contact. Therefore, the Board finds that the Veteran's depression does not result in total social impairment. As previously stated, a 100 percent disability 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. The evidence does not show these symptoms, or symptoms of the kind listed that indicate the level of occupational and social impairment associated with a 100 percent rating. The Board has also considered the Veteran's GAF scores assigned during the course of the appeal. The Veteran's GAF scores assigned during VA treatment and VA examinations ranged from 53 to 65. June 2012 and August 2010 examination reports show that Dr. W.A. assigned the Veteran a GAF score of 41. GAF scores from 61 to 70 indicate 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, and has some meaningful interpersonal relationships. GAF scores from 51 to 60 indicate more 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). GAF scores from 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). GAF scores from 31 to 40 indicate some impairment in reality testing or communication 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 was unable to work). GAF scores from 21 to 30 indicate that behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). 38 C.F.R. § 4.125; DSM-IV. The majority of the Veteran's assigned GAF scores during the course of the appeal were between 51 and 60, indicating moderate symptoms. 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). The Board acknowledges that the Veteran has been assigned a GAF score of 41, by Dr. W.A., on two separate occasions. A GAF score of 41 indicates serious symptoms such as suicidal ideation and severe obsessional rituals or any serious impairment in social or occupational functioning. These symptoms are not consistent with a100 percent rating as they do not rise to the level of total occupational and social impairment. Therefore, the Board finds that the Veteran is not entitled to a rating in excess of 70 percent for her depression. The Board has considered whether staged ratings under Hart, supra, are appropriate; however, the Board finds that her symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted 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 that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. 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. Second, 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 "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Thun, 22 Vet. App. at 115-16. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected depression with the established criteria found in the rating schedule. The Board finds that the Veteran's depression symptomatology is fully addressed by the rating criteria under which such disability is rated. There are no additional symptoms of her depression that are not addressed by the rating schedule. In this regard, all of the Veteran's psychiatric symptomatology is contemplated by the rating criteria, to include those symptoms which are not specifically enumerated. See Mauerhan, supra. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of her service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Thun, 22 Vet. App. at 115-16; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this case, as indicated previously, the Veteran has been awarded a TDIU based on her depression for the entire appeal period, i.e., effective October 21, 2009, the date VA received her increased rating claim. Therefore, further consideration of such issue is not necessary. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to a rating in excess of 70 percent for depression. As such, that doctrine is not applicable in the instant appeal, and the Veteran's claim must be denied. 38 U.S.C.A. § 5107. ORDER A rating in excess of 70 percent for depression is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs