Citation Nr: 1335209 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 10-32 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES Entitlement to an initial increased disability evaluation for an acquired psychiatric disorder, to include dysthymic disorder, adjustment disorder, depression, anxiety, and posttraumatic stress disorder (PTSD) (hereinafter "psychiatric disorder"), currently evaluated as 10 percent disabling from June 13, 2007 to July 28, 2008; 30 percent disabling from July 29, 2008, to May 21, 2013; and 50 percent disabling from May 22, 2013. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD H. Hoeft, Counsel INTRODUCTION The Veteran served on active duty from December 2004 to June 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York, which granted service connection for a dysthymic disorder (claimed as adjustment disorder, anxiety, and depression). The RO assigned an initial disability rating of 10 percent, effective June 13, 2007. In a statement received in August 2008, the Veteran requested an increased rating for depression due to worsening symptoms. That correspondence did not express disagreement with the initial rating assignment and does not meet the requirements of a notice of disagreement under 38 C.F.R. § 20.201. However, within a year of the issuance of the February 2008 determination, new and material evidence was received, in the form of the VA outpatient mental health records addressing symptomatology directly relevant to the rating criteria in question and a December 2008 VA mental examination. See, e.g., September 2008 VA Psychological Evaluation. Accordingly, although not appealed, the February 2007 rating decision never became final and thus the entire appeal period from June 13, 2007, remains on appeal. 38 C.F.R. § 3.156(b). In light of these facts, the issue currently on appeal is more appropriately characterized as entitlement to increased initial ratings for depression, as delineated on the cover page of this decision. A February 2009 rating decision added PTSD to the service-connected disability and then increased the disability rating for the acquired psychiatric disorder to 30 percent, effective August 13, 2008. The Veteran continued to appeal, requesting even higher ratings. See AB. v. Brown, 6 Vet. App. 35, 38-39 (1993) (indicating that a Veteran is presumed to be seeking the highest possible rating unless he or she expressly indicates otherwise). A June 2009 rating decision found a clear and unmistakable error in the February 2009 rating decision, and changed the effective date for the 30 percent rating from August 13, 2008, to July 29, 2008. The Veteran continued to appeal, requesting even higher ratings. Id. In April 2013 the Board remanded the claim for further development. Most recently, in a May 2013 rating decision, the RO increased the rating for the acquired psychiatric disorder to 50 percent, effective May 22, 2013. The appeal continues for a higher rating continues. Id. The Board notes that the Veteran requested a hearing in her August 2010 substantive appeal. In an August 2012 letter, she was notified that her hearing had been scheduled for August 29, 2012, but she failed to appear for the proceeding and has not provided an explanation for her absence or requested to reschedule the hearing. Accordingly, the Board considers her hearing request to be withdrawn. 38 C.F.R. § 20.704(d)(2013). The Veteran's Virtual VA paperless claims file was also reviewed and considered in preparing this decision. FINDINGS OF FACT 1. From June 13, 2007 to July 28, 2008, the Veteran's service-connected psychiatric disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms; but the higher rating requiring occupational and social impairment, with reduced reliability and productivity, is not shown during this period. 2. From July 29, 2008, to May 21, 2013, and since May 22, 2013, the Veteran's service connected psychiatric disorder was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms; but the higher rating requiring occupational and social impairment, with deficiencies in most areas, is not shown during this period. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 30 percent for an acquired psychiatric disorder, to include dysthymic disorder, adjustment disorder, depression, anxiety, and PTSD, for the period of June 13, 2007 to July 28, 2008, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433 (2013). 2. The criteria for an initial evaluation of 50 percent for an acquired psychiatric disorder, to include dysthymic disorder, adjustment disorder, depression, anxiety, and PTSD, for the period of July 29, 2008, to May 21, 2013, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433 (2013). 3. The criteria for an initial evaluation of 50 percent for an acquired psychiatric disorder, to include dysthymic disorder, adjustment disorder, depression, anxiety, and PTSD, for the period from May 22, 2013, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act (VCAA) provides that 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); 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of what is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). The VA 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. 38 C.F.R. § 3.159(b)(1) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). All notice under the VCAA should be provided prior to an initial decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). However, the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements: (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. See 38 U.S.C. § 5103(a) (West 2002). Compliance with the first Quartuccio element requires notice of these five elements. See id. at 486. The VCAA further provides that VA has a duty to assist the veteran in the development of the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2013). This duty includes assisting him in obtaining service treatment records and other pertinent treatment records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See id. The Board finds that the duty to notify has been satisfied. Where, as here, the increased-rating claim arose in another context, namely, the Veteran trying to establish her underlying entitlement to service connection, and the claims since have been granted and he has appealed these "downstream" issue concerning the initial rating and effective date assigned for his disability, the underlying claim has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the initial intended purpose of the notice has been served. See Goodwin v. Peake, 22 Vet. App. 128 (2008). Thereafter, once a notice of disagreement (NOD) has been filed contesting the "downstream" issue of the initial rating assigned for the disability, the notice requirements of 38 U.S.C. §§ 5104 and 7105 regarding a rating decision and SOC control as to the further communications with her, including as to what evidence is necessary to establish a more favorable decision with respect to this downstream elements of the claims. Id.; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) and VAOPGCPREC 8-2003 (Dec. 22, 2003). The Veteran received this required notice most recently in June 2012 and May 2013 Supplemental Statements of the Case discussing her downstream claim for a higher initial rating citing the applicable statutes and regulations, and providing reasons and bases for not assigning a higher. She was informed of the evidence required to substantiate the claim and of her and VA's respective responsibilities in obtaining this supporting evidence, as well as the "downstream" disability rating and effective date elements of her claims. Thus, no further notice is required. See Goodwin v. Peake, 22 Vet. App. 128 (2008) and Huston v. Principi, 17 Vet. App. 195 (2003). The Board also concludes that the duty to assist has also been satisfied. The Veteran's service treatment records (STRs) and post-service medical records have been associated with the claims file. The Veteran has not identified any other outstanding records that she wanted VA to obtain or that she felt were relevant to the present claim. The Veteran has also been afforded VA examinations, most recently in May 2013 for information and for evaluation of her psychiatric disability. The Board finds the examination reports to be adequate for adjudication on the merits. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). Finally, the Board finds that there has been substantial compliance with its April 2013 remand directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran was afforded a VA compensation examination which was conducted in accordance with the Board's directives. In sum, the record reflects that the facts pertinent to the claim have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate her claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claim on the merits. II. Increased Ratings As an initial matter, it is important to point out that where a Veteran appeals the rating initially assigned for a disability, after already having established service connection for it, VA must consider the propriety of a staged rating that is indicative of changes in the severity of the course of her disability over time. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court recognized a distinction between a veteran's dissatisfaction with an initial rating assigned following a grant of service connection and a claim for an increased rating of a service-connected disorder. In the case of the assignment of an initial rating for a disability following an initial award of service connection for that disability (the circumstances of the present appeal), separate ratings can be assigned for separate periods of time based on the facts found - "staged" ratings. See Fenderson, supra, at 125-26. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). As discussed in the above Introduction, the Veteran was granted service connection for a psychiatric disorder (dysthymic disorder, claimed as adjustment disorder, anxiety and depression with PTSD) in a February 2008 decision and assigned a 10 percent disability rating, effective from June 2007. She appealed this initial disability rating, and in a February 2009 rating decision, the RO increased the disability rating to 30 percent effective August 13, 2008. In a June 2009 rating decision, the RO found CUE in the effective date assigned for the 30 percent rating, and assigned a 30 percent rating effective July 29, 2008. In May 2013, the RO, subsequent to a Board remand, increased the rating to 50 percent, effective from May 22, 2013. The Veteran's disability evaluation has therefore already been staged and each rating will be discussed separately. See Fenderson, supra. The Veteran's psychiatric disability is evaluated pursuant to 38 C.F.R. § 4.130, DC 9433 (2013). Under DC 9433, the criteria for a 10 percent rating are 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. The criteria for the next higher rating, 30 percent, are 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). Id. The criteria for a 50 percent rating are 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; and difficulty in establishing and maintaining effective work and social relationships. Id. 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. Id. A 100 percent rating requires 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 of names of close relatives, own occupation or own name. Id. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health- illness." DSM-IV at 32. GAF scores ranging from 61 to 70, for example, reflect 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. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect 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). Scores ranging from 31 to 40 reflect 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 younger children, is defiant at home, and is failing at school). See Carpenter v. Brown 8 Vet. App. 240, 242 (1995). III. Factual Background. The Veteran underwent a VA examination in October 2007, at which time she reported that she was currently unemployed, but actively seeking employment. She stated that she had a number of close friends and a very close and supportive relationship with her mother. She indicated that she received social support from her mother's side of the family and had good relationships with them as well. She stated that she had a positive relationship with her daughter, but some interpersonal conflict with her father. The Veteran was able to maintain basic activities of daily living. She reported that she experienced depressive symptoms at least one a day, including sadness, irritability, lack of motivation, loss of appetite, difficulty sleeping, fatigue, and loss of energy. She denied any significant concentration difficulties and also reported that she was still able to enjoy the things that she used to enjoy, including spending time with her daughter. She stated that she was not currently interested in any psychotherapy or treatment for her depression. Objectively, she was neatly dressed, alert, and oriented. She denied perceptual disturbances; thought content was within normal limits; thought processes were coherent, logical, goal oriented, and appropriate; mood was dysphoric; and affect was congruent. The Veteran denied any suicidal or homicidal ideation. Her speech was normal rate, rhythm, spontaneous normal volume. Insight and judgment were good. She was described by the examiner as pleasant and cooperative; her behavior was described as normal. The examiner summarized that her symptoms were consistent with dysthymic disorder as evidence by her chronic depressed mood, poor appetite, insomnia, and fatigue; although the Veteran reported adequate social functioning and continued attempts to find employment, her symptoms caused her significant distress and negatively impacted her ability to engage in activities as effectively as she would like. The examiner described the psychiatric incapacity due to such symptoms as "mild." A GAF score of 63 was assigned. A September 2008 VA mental health note reflects that the Veteran was feeling down, with depressed mood and anxiety. She reported nightmares, forgetfulness, and difficulty focusing/concentrating, which often affected her at work. She stated that she had very few friends and had lost interest/motivation in doing things. She denied feeling hopeless and/or having suicidal or homicidal ideation. Objectively, she was well-dressed, cooperative, and engageable. Her mood was depressed, with an anxious affect, and she was tearful at times. Her speech was normal and thoughts were clear and organized. There was some difficulty with attention and concentration during the interview, but redirectable. She had no difficulties with memory. She was oriented. Insight and judgment were good. In sum, the examiner stated that the Veteran had a history of childhood trauma and dysthymia since the military, and currently presented with increasing symptoms of depression related to ongoing psychosocial stressors (i.e., adjusting to new job, strained relationship with her daughter's father, financial concerns, and few social supports). Depressive symptoms included feeling down, tearfulness, insomnia, loss of interest/motivation, poor concentration, low energy, and symptoms of anxiety and PTSD (related to childhood trauma and verbal abuse in the military), with nightmares, avoidance, and increased arousal. A GAF score of 62 was assigned. An October 2008 VA mental health note reflected that the Veteran was well-groomed; her affect was appropriate; and her mood was neutral. She complained of restless nights with reoccurring nightmares, which left her exhausted and unable to get back to sleep. Suicidal/homicidal ideation was not present. She reported no significant stressors at home or work. Another mental health note, also dated in October 2008, revealed that her mood was "so-so" and her affect was neutral. She was oriented and insight/judgment were fair. Yet another mental health note dated in October 2008 showed complaints of depression with mood swings; the Veteran stated that she was paranoid that people were talking about her and sometimes felt that someone was following her/calling her name. Bipolar disorder was suspected. She reported current feelings of depressed mood, social isolation, and intermittent nightmares with fatigue. No psychosis, mania, or suicidal/homicidal ideations were present. Judgment and insight were fair. A November 2008 VA mental health note reflected that the Veteran was in a neutral mood with a congruent affect. She reported that her nightmares had lessened. She stated that she no longer perceived that she was being followed; no hallucinations/delusions were present. A November 2008 VA mental health note reflected that the Veteran's mood was euthymic with a congruent affect. She was at ease and smiling. She verbally acknowledged a decrease in nightmares, but stated that she was having flashbacks of childhood atrocities that she witnessed. She expressed concern about her mood swings, stating that she was happy when interacting with her child and mother, but unhappy when recalling events of her past. She denied grandiosity, distractibility, racing thoughts, acute sleep loss, rapid speech, and suicidal thoughts. A December 2008 letter from the Veteran's VA treating mental specialist, C.M., stated that the Veteran's dysthymic disorder had "worsened." The Veteran reported feeling persecuted by her superior. She also endorsed recurrent nightmares and fatigue. She stated that she had been sad all throughout her life, but became more "saddened during her military experience, especially when she overheard her superior talking badly about her....she feel that her current supervisor behaves towards her in very much the same manner." She reported current feelings of depressed mood and social isolation. She continued to be socially inhibited and relied on her relationship with her mother as a social outlet. C.M. stated that the Veteran had difficulty with change and therefore her progress was poor. A December 2008 VA mental health note reflected that the Veteran presented with a slightly saddened mood and congruent affect. She reported having another scary nightmare which disrupted her sleep; she currently felt nervous and jittery. She was encouraged to discuss any immediate stressors that could be represented by the nightmare and reported that she was in a relationship with a married man and felt guilty about the circumstances. The Veteran underwent a VA mental examination in December 2008. The report notes that she was employed full-time and enjoyed her job. She did report interpersonal tension with her coworkers. She also reported that she felt ignored at work and felt that she was treated differently due to her culture and foreign appearance. She denied getting into arguments at work, but stated that she felt a great deal of stress from the tension of these interpersonal conflicts. The Veteran stated that she was the sole support for her family and mother. She reported an excellent relationship with her mother and daughter, but poor relationships with her father and father of her child. She reported having several friends with whom she interacted with daily. She complained of feeling very tired after work but she was still able to take care of her daughter. Once a month, she reported feeling so tired that she would spend the weekend in bed. Usually, however, she would go out with her mother and daughter to the museums. Subjectively, the Veteran complained of sleeping problems, nightmares, periods of low energy during the day, loss of pleasure (except when spending time with her daughter), low mood, loss of appetite once every 2 weeks, feelings of being singled out at work, hearing her name being called at night when she is walking home, and episodes of losing her sense of direction. She also reported checking the windows, doors, her mother, and daughter every night after waking up from her nightmares. She did exhibit good behavioral control and denied irritability or violent behavior. Objectively, the Veteran was dressed and groomed neatly. She was cooperative, but appeared drowsy at times. Her motor functioning was unremarkable. Her speech was within normal limits. Her mood was dysthymic; affect was constricted; and thinking was logical and goal directed without loosening of association. Thought content contained paranoid ideation about being followed and a feeling of persecution by her fellow employees and boss. She denied homicidal/suicidal ideation. She reported an auditory hallucination that she hears at night when returning from work of hearing her name called. She also noted hearing noise when concentrating on something. The examiner noted that she was oriented to time, person, and place. Her memory was intact, but evidenced some difficulty with immediate recall. She exhibited adequate attention and concentration. Her capacity for judgment and insight were fair. Her behavior was appropriate. In sum, the examiner stated that her mental disorder was affecting her relations with her co-workers and superiors; however, she was not missing work and was able to perform her job functions. Her mental disorder also affected her social life by way of restricting her ability to form outside relationships, although she did have some friendships. Overall, the Veteran displayed occasional decrease in her work efficiency and intermittent periods of being unable to perform certain family tasks due to her mental disorder. Her functioning, however, was generally satisfactory. A GAF score of 60 was assigned. A March 2009 VA mental health note reflected that the Veteran was distressed over being in a dysfunctional relationship with a married man; her distress over this issue was leading to a series of frightful nightmares, indecision, loss of sleep and general low mood. Objectively, she was neatly dressed and well-groomed. Her mood was euthymic and her affect was in harmony with mood and current situation. There was no evidence of cognitive impairment and sensorium was intact. Her speech was clear, coherent, and relevant. Judgment and insight were less than fair. An April 2009 VA mental health note reflected that the Veteran presented with dysthymic mood; affect was congruent with sad mood. She was well-dressed and groomed. She denied delusions and hallucinations and displayed no evidence of impaired or distorted thinking. Insight and judgment had improved and were fair. She reported that her nightmares continued. Some degree of relapse was noted during the session. She denied any ideation, intent, or plan to harm herself and left the clinic with no signs of acute distress. A May 2009 VA mental health note reflected that the Veteran denied homicidal/suicidal ideation, intent, or plan. She denied delusions/hallucinations and exhibited no signs of impaired cognition or sensorium. Judgment and insight were impaired. She exhibited diminished capacity for evaluating, assessing, or understanding true cause and meaning for her current situation in an intimate relationship with a married man. She continued to experience nightmares and fluctuated between dysthymic and rare episodes of euthymic mood. Her depressed mood dominated her mental life but did not create a state of dysfunction for her. A June 2009 letter from the Veteran's treating VA psychiatrist, Dr. P., indicated that the Veteran's dysthymic disordered had "worsened." He noted that the Veteran was seen weekly in therapy and that she complained of recurrent nightmares of swimming in a pool of blood; the nightmare left her exhausted and not wanting to get up. She also had panic attacks following her nightmares, to include panic attacks at work and startle reaction whenever the phone would ring at work. Dr. P indicated that the Veteran was nervous and felt frightened for no apparent reason. She was also forgetful and her short term memory was impaired at times (e.g., she would forget what day of the week it was and had trouble following directions and remembering to pay bills). She had little support system other than her mother. She was unable to form committed relationships. She reported current feelings of depressed mood and social isolation and this was reflected in her social life. She continued to be socially inhibited and relied on her relationship with her mother as a social outlet. Dr. P. noted that she was socially impaired and had difficulty with change, and therefore, her progress was poor. In sum, she remained "depressed and her dysthymic disorder has worsened related to her social life and her thinking." VA outpatient treatment records dated in 2010 reflect ongoing treatment for depressive symptoms. The Veteran underwent a VA mental examination in May 2013. The Veteran had married since her last examination and currently lived with her husband, mother, sister and daughter. She described her marriage as friendly but not necessarily close; she did state that she has a close friend. She stated that she "goes out infrequently, but is reluctant to spend time in public because she thinks people may thinking derogatory things about her (this is likely a symptom of her dysthymic disorder)." She stated that she felt overwhelmed, in general, with having to take care of "everybody." She was currently employed as an eligibility clerk at the VA, where she felt she did a very good job supporting Veterans. She did not report significant occupational impairment due to depression; in fact, she stated that she was less likely to entertain self-referential ideas when she was busy. According to her records, the examiner stated that the Veteran had not received treatment from a mental health clinician since 2010. She had prescriptions for trazodone and citalopram hydrobromide but apparently decided not to take them. She also decided not to pursue further counseling or psychotherapy after 2010. Current symptoms included depressed mood, anxiety, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. She also reported ideas of reference (but no true delusions or hallucinations) associated with her depression. She also reported nightmares, many of them related to her experiences of being harassed in the military (also likely symptoms of her depression). The examiner noted that the Veteran's dysthymic disorder encompassed symptoms diagnosed at different times as major depressive disorder, dysthymic disorder, adjustment disorder, and PTSD. The examiner noted occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. A GAF score of 57 was assigned. There is no additional relevant evidence dated after the May 2013 VA examination. IV. Analysis Again, the Veteran was awarded a 10 percent rating for dysthymic disorder from June 13, 2007, until July 28, 2008; a 30 percent rating from July 29, 2008, until May 21, 2013; and a 50 percent rating from May 22, 2013 to the present. She asserts the assigned ratings are inadequate and should be increased. (i) Initial Evaluation for Dysthymic Disorder, Evaluated as 10 percent Disabling From June 13, 2007 to July 28, 2008. The Board has reviewed the entirety of the evidence outlined above, and concludes that for the period from June 13, 2007, to July 28, 2008, an increased rating of 30 rating for dysthymic disorder is warranted, but not higher. Specifically, a review of the medical evidence from this time frame, which consists solely of an October 2007 VA examination report, reflects a GAF score of 63, with primary symptoms of depressed mood, poor appetite, insomnia, and fatigue. Again, under DSM-IV, GAF scores from 61 to 70 generally reflect 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 having some meaningful relationships. (Emphasis added). After reviewing the evidence of record for the period from June 13, 2007, to July 28, 2008, the Veteran's dysthymic disorder has been determined to be productive of some (or, mild) occupational and social impairment and mild psychiatric symptoms, consistent with GAF scores in the range of 61 to 70, and commensurate with the 30 percent rating criteria under the General Rating Formula. See Diagnostic Code 9411. Indeed, the October 2007 VA examiner expressly noted that, while the Veteran's psychiatric symptoms "cause significant distress and negatively impact her ability to engage in activities as effectively as she would like," her incapacity (social and occupational) due to such symptoms was only "mild." Supporting this conclusion is the fact that the Veteran maintained very close relationships with several friends, her mother, and her daughter, and was actively seeking employment during this time period (note: in fact, later-dated VA outpatient treatment records confirm that the Veteran obtained employment on a full-time basis "biller" at a VA facility that same month, i.e., October 2007). Thus, in considering the totality of the evidence, and resolving any doubt in favor of the Veteran, the Board concludes that the record as a whole demonstrates 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), such that an increased initial rating of 30 percent is warranted. Notably, each of the factors listed in the criteria for a 30 percent rating need not be demonstrated for the assignment of that disability rating. See Mauerhan, 16 Vet. App. at 442-43. Although the Veteran has not been shown to experience panic attacks, mild memory loss, or suspiciousness during the time period in question here, she did endorse depression (depressed mood) and insomnia (chronic sleep impairment) consistent with the criteria for a 30 percent disability rating. The Board notes in this regard that the Veteran is competent to report experiencing symptoms such as sleep impairment, depressed mood, decreased appetite, and fatigue, and that the Board finds the Veteran's statements regarding such in this case to be credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). In next addressing whether the Veteran is entitled to an initial rating higher than 30 percent for the period from June 13, 2007, to July 28, 2008, the Board concludes that she is not. The evidence of record does not support a finding that the Veteran's dysthymic disorder is manifested by 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; or difficulty in establishing and maintaining effective work and social relationships. In fact, the objective mental status findings from the October 2007 VA examination report reflected that the Veteran's judgment and insight were good; her speech, thought process, and behavior were normal; and she reported having a number of close friends, to include a very close and supportive relationship with her mother and a positive relationship with her daughter. The Veteran was also actively seeking employment, and, as noted above, ultimately obtained employment later that month. For the reasons outlined above, a rating in excess of 30 percent for the pertinent period on appeal is not warranted here. In short, the medical and lay evidence demonstrates that the Veteran is entitled to an initial evaluation of 30 percent for the period from June 13, 2007, to July 28, 2008, but not higher. As the preponderance of the evidence is against an initial evaluation in excess of 30 percent, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). (ii) Initial Evaluation for Dysthymic Disorder, Evaluated as 30 Percent Disabling From July 29, 2008, to May 21, 2013, and 50 Percent Disabling Since May 22, 2013 The Board has considered the entirety of the evidence and concludes that for the entire period from July 29, 2008, until May 21, 2013, and since May 22, 2013, an initial 50 rating for dysthymic disorder is demonstrated, but not higher. In other words, an increased initial rating from 30 to 50 percent is warranted from July 29, 2008, to May 21, 2013; and thereafter, no more than a 50 percent rating is warranted. A review of the medical evidence during this time frame, which consists of numerous VA outpatient mental health notes dated from September 2008 to May 2013, letters from the Veteran's treating psychiatrist dated in December 2008 and June 2009, and VA examinations conducted in September 2008, December 2008, and May 2013, shows GAF scores ranging from 57 to 62 (the predominate GAF's being in the 55 to 60 range), with psychological symptomatology primarily consisting of panic attacks (less than once a week), social isolation, nightmares, suspiciousness (paranoia), impaired judgment, impaired memory, disturbances in motivation/mood, and difficulties in establishing/maintaining effective work and social relationships. Again, under DSM-IV, scores of 55 and 60, as assigned here, generally reflect 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 coworkers). (Emphasis added). Thus, as supported by the evidence of record, the Veteran's symptoms of dysthymic disorder more nearly approximate the level of impairment associated with a 50 percent evaluation. In light of the evidence as noted above, the Board concludes that the Veteran's dysthymic is productive of impairment warranting a 50 percent under DC 9433 for the period from July 29, 2008, until May 21, 2013, and since May 22, 2013. As for the potential for a higher rating, the Board notes that from July 29, 2008, until May 21, 2031, and since May 22, 2013, the evidence did not demonstrate that the service-connected psychological disorder was productive of occupational and social impairment with deficiencies in most areas or an inability to establish and maintain effective relationships. Indeed, while the Veteran may have suffered from some level of social impairment, in that she was socially inhibitive/isolative, the evidence does not show that she was necessarily prevented from establishing and maintaining such relationships. In so finding, the Board acknowledges the June 2009 letter from the Veteran's treating psychologist noting that she was "unable to form committed relationships." However, the evidence has demonstrated time and again, that the Veteran maintained (and still maintains) a very significant and close relationship with both her mother and her daughter and also engaged in regular activities outside of the home with her family (e.g., going to museums, etc.). As for industrial impairment, it is noted that the Veteran has been employed on a full-time basis since 2007; at her most recent VA examination in May 2013, she expressly denied significant occupational impairment due to depression. In other statements of record, she reported that she enjoyed her job, and this was so in spite of interpersonal tension with her coworkers. Again, such evidence does not necessarily reflect an inability to establish work relationships, only that her psychological disability makes it difficult for her to do so (and this expressly contemplated by the 50 percent rating assigned). Based on the above, the Veteran's psychological disorder is not shown to be so disabling so as to warrant an evaluation of 70 percent under DC 9433. In making the above determination, the Board finds it probative that she has not demonstrated the symptoms typical in the GAF scale for serious symptoms (suicidal ideation, severe obsessional rituals, frequent shoplifting, and unable to keep a job). Moreover, there was no evidence of 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; or difficulty in adapting to stressful circumstances (including work or a work-like setting). See Diagnostic Code 9433. The Board is aware that the symptoms listed under the 70 percent rating and in the GAF scale are examples of the type and degree of symptoms for that evaluation, and that the Veteran need not demonstrate those exact symptoms to warrant a 70 percent evaluation. See Mauerhan, supra. However, as summarized above, the record does not show that the Veteran has manifested symptoms that equate to or more nearly approximate the criteria for a 70 percent rating. In sum, the Veteran's psychiatric disorder was not (and is not) manifested by psychiatric symptomatology that approximates, or more nearly approximates, the criteria for an evaluation in excess of 50 percent for the period from July 29, 2008, until May 21, 2013, and since May 22, 2013, under DC 9433. See 38 C.F.R. § 4.7. Lastly, the Board notes that there is limited evidence showing that the Veteran heard voices (i.e., someone calling her name), and perceived that she was being followed along with other paranoid thoughts. Specifically, on two occasions, once in October 2008 and again in December 2008, she reported such symptoms. The contemporaneous VA medical reports expressly noted that no psychosis or mania was present; that her insight and judgment were fair; and that her behavior was appropriate. The December 2008 examiner also assigned a GAF score of 60, reflecting moderate (not serious) symptoms. To the extent that the Veteran's limited reports of being followed and/or hearing voices amount to mere suspiciousness, the Board notes that such symptomatology is encompassed in the 30 percent rating criteria under the General Rating Formula. See Diagnostic Code 9433. To the extent that such symptoms amount to auditory hallucinations, the Board notes that General Rating Formula provides for a higher 100 percent rating when there is total occupational and social impairment due to various symptoms, including "persistent delusions or hallucinations." Again, the Veteran reported hearing voices on no more than two occasions throughout the course of this appeal (spanning nearly five years); the Board does not find that two such episodes amount to the "persistent" hallucinations contemplated by the General Rating Formula. Moreover, there is no evidence, whatsoever (nor has the Veteran ever claimed), that these symptoms result in the level of occupational and social impairment required for a 100 percent rating (i.e., total impairment). Thus, while the Veteran may have exhibited some of the criteria for a 100 percent rating, see Mauerhan, supra, the Board concludes her overall level of disability does not exceed the criteria for a 50 percent rating for the reasons discussed immediately above. The Board has considered the Veteran's statements that her disability is worse than evaluated. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gilbert, supra. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see Layno, supra. In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. Layno, 6 Vet. App. at 470. However, far more probative are the examination reports prepared by skilled professionals. Such competent evidence concerning the nature and extent of the Veteran's mental disability has been provided by the medical personnel who have examined her during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. The Board finds that the Veteran has presented credible lay evidence. However, such evidence does not provide a basis for a higher evaluation. Furthermore, other than requesting higher evaluations, her pleadings have been non-specific. However, the Board does find that the Veteran's reports to the examiner to be competent and credible. As such, the Board finds the examination reports to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). In short, the medical evidence demonstrates that for the entire period from July 29, 2008, until May 21, 2013, and since May 22, 2013, an initial 50 rating for dysthymic disorder is demonstrated, but not higher. As the preponderance of the evidence is against an initial evaluation in excess of 50 percent, the benefit of the doubt doctrine is not for application. See generally Gilbert, and Ortiz, supra. V. Extraschedular Considerations The Board finds that at no point since the date of the claim has the service-connected psychiatric disability been shown to be so exceptional or unusual as to warrant the assignment of a rating higher than 30 percent from June 13, 2007 to July 28, 2008; and 50 percent from July 29, 2008, to May 21, 2013, and since May 22, 2013, on an extraschedular basis. See 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedural Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extraschedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or the Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Thun, supra. In this case, the Board finds that the schedular criteria are adequate to rate the Veteran's psychiatric disability. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than those assigned based on more significant functional impairment. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). VI. TDIU Consideration In granting in part and denying in part the Veteran's claim for increased rating, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the evidence reflects that the Veteran is currently employed full-time. Accordingly, the Board concludes that a claim for TDIU has not been raised per Rice. ORDER An initial disability rating of 30 percent, and no higher, for an acquired psychiatric disorder, to include dysthymic disorder, adjustment disorder, depression, anxiety, and PTSD, is granted from June 13, 2007 to July 28, 2008, and is subject to statutory and regulatory provisions governing the payment of monetary benefits. An initial disability rating of 50 percent, and no higher, for an acquired psychiatric disorder, to include dysthymic disorder, adjustment disorder, depression, anxiety, and PTSD, is granted from July 29, 2008, to May 21, 2013, and is subject to statutory and regulatory provisions governing the payment of monetary benefits. An initial disability rating greater than 50 percent for an acquired psychiatric disorder, to include dysthymic disorder, adjustment disorder, depression, anxiety, and PTSD, for the period since May 22, 2013, is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs