Citation Nr: 1335246 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 07-32 119 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to a higher initial ratings (evaluations) for mood disorder due to cardiac arrest, with depressive-like episodes (formerly depressive disorder), in excess of 30 percent from February 1, 2006 through May 18, 2007; and in excess of 50 percent from May 19, 2007 through February 24, 2011. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from January 1986 to January 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, which, in pertinent part, granted service connection for depression, evaluating the disorder as 30 percent disabling. This appeal arises from the Veteran's disagreement with the initial disability rating assigned by the RO for the depressive disorder. The Veteran requested a hearing before the Board, to be held at the RO, but subsequently withdrew the request in writing. In the August 2006 rating decision on appeal, the RO granted service connection for gout, evaluating the disorder as noncompensable (zero percent disabling); granted service connection for degenerative changes of the right knee, evaluating the disorder as 10 percent disabling; granted service connection for degenerative changes of the left knee, evaluating the disorder as noncompensable (zero percent disabling); and denied service connection for internal and external hemorrhoids. Subsequently, the Veteran filed a Notice of Disagreement (NOD), disagreeing with the initial ratings assigned for gout, degenerative changes of the right knee, and degenerative changes of the left knee disabilities, and the denial of service connection for hemorrhoids. In September 2009, the RO granted a higher initial rating for degenerative changes of the left knee, evaluating the disorder as 10 percent disabling, effective March 7, 2008. The Veteran subsequently appealed these issues to the Board. In a September 2010 Board Decision and Remand, the Board, in pertinent part, denied a higher initial rating for depression, in excess of 30 percent from February 1, 2006 and in excess of 50 percent from May 9, 2007. The RO had previously assigned the Veteran an evaluation of 50 percent effective May 19, 2007 and the Board's use of the date May 9 was in error. Nonetheless, the Veteran appealed the issues addressed in the September 2010 Board Decision and Remand, other than service connection for hemorrhoids, to the U.S. Court of Appeals for Veterans Claims (Court). While the case was pending at the Court, VA's Office of General Counsel and the Veteran's representative filed a Joint Motion for Partial Remand (Joint Motion), requesting that the Court vacate the portion of the Board's September 2010 decision denying higher initial ratings for depression, in excess of 30 percent prior to May 9, 2007; and in excess of 50 percent from May 9, 2007. In January 2012, the Court issued an Order granting the Joint Motion, thereby vacating that portion of the Board's September 2010 Decision. To the extent that the Board previously erred in considering the Veteran's 50 percent rating as having been assigned effective May 9, 2007, the Decision has been vacated and with it the Board's error. Additionally, in a rating decision of February 2012, the RO restyled the disability as "mood disorder due to cardiac arrest, with depressive-like episodes (formerly depressive disorder)." Accordingly, the issue indicated above reflects both the correct dates of the Veteran's staged rating on appeal, and the RO's change in description of the disability at issue. In the Joint Motion, the parties specifically agreed not to disturb the portions of the September 2010 Board Decision denying higher initial ratings for gout, degenerative changes of the right knee, and degenerative changes of the left knee, respectively; thus these matters are no longer before the Board. The Court's January 2012 Order granting the Joint Motion, remanded the issue of entitlement to higher initial ratings for depression to the Board for further development in accordance with the Joint Motion. The Board, then remanded the matter to the RO for additional development pursuant to the Joint Motion, to include the identification of treatment records not associated with the claims file, association with the claims file of specific records identified by the Veteran, and issuance of a supplemental statement of the case. The requested development has been conducted and in July 2013 a supplemental statement of the case of issued to the Veteran. Therefore, the Board finds that the RO complied with the January 2012 remand directives regarding higher initial ratings for depression. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). In the September 2010 Decision, the Board remanded the Veteran's claim for service connection for internal and external hemorrhoids for further development. The record indicates that the RO has not yet complied with the ordered development of the remanded claim for service connection; therefore, that issue is not currently before the Board and is referred to the AOJ for appropriate action In February 2011, while the appeal for a higher initial rating for depression was pending at the Court, the Veteran filed additional claims for increased ratings for depression, gout, lumbar strain, and tension headaches as well as claims to reopen previously denied claims of service connection for pinguecula of the right eye, carpal tunnel syndrome, sleep apnea, and a right hand disorder. The RO has not yet issued a rating decision regarding the Veteran's February 2011 claims. As to the February 2011 claim of higher initial ratings for depression, this claim presently on appeal before the Board and thus is redundant. Nonetheless, the remaining claims regarding gout, lumbar strain, tension headaches, pinguecula of the right eye, carpal tunnel syndrome, sleep apnea, and a right hand disorder have been raised by the record by have not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The Veteran's Law Judge who adjudicated the September 2010 Decision and Remand is no longer employed with the Board; therefore, the undersigned Veteran's Law Judge has been assigned this claim. A review of the Virtual VA paperless claims processing system reveals documents relating to the immediate appeal, including VA treatment records. These documents are considered to be part of the claims file and as such have been considered as part of the present appeal. FINDING OF FACT Throughout the entire initial rating period on appeal from February 1, 2006, mood disorder due to cardiac arrest, with depressive-like episodes has been productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as a flattened affect; stereotyped speech; panic attacks; impairment of concentration; suicidal ideation; disturbances of motivation and mood; and difficulty in maintaining effective social relationships. CONCLUSION OF LAW The criteria for an initial rating of 50 percent, but no more, for mood disorder due to cardiac arrest, with depressive-like episodes have been met throughout the initial rating period on appeal, from February 1, 2006 through February 24, 2011. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130, Diagnostic Code 9435 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties 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 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Proper notice from 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). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the decision of the Court in Dingess v. Nicholson, 19 Vet. App. 473 (2006) requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. The Veteran's appeal arises from an appeal of the initial evaluation following the grant of service connection for depression - now mood disorder. Once service connection is granted the claim is substantiated, additional notice is not required. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). Based on the foregoing, adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), and no further notice is needed under VCAA. Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2013); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). In this case, service records have been obtained, as have records of pertinent medical treatment. These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issue before the Board. Furthermore, VA has complied with the January 2012 Joint Motion for Remand to the extent that the motion identified deficits in VA's duty to assist in previous, now vacated, adjudications of the Veteran's appeal. The Veteran was afforded VA examinations in May 2006, May 2007, July 2009, and September 2011. During these examinations, the examiners conducted psychological examinations of the Veteran, took down the Veteran's history, considered lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions regarding the Veteran's mental health based on history and examination that are consistent with the record. In the case of all four examinations, the VA examiners did not indicate whether the claims file was reviewed, though they did cite to specific evidence of record suggesting that such a review was conducted. Nonetheless, assuming that the claims file was not reviewed in any of the four VA examinations, accurate histories were elicited from the Veteran regarding mental health symptomatology - and these histories were otherwise consistent with the record. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner assessment based on accurate lay history deemed competent medical evidence in support of the claim). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2013); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). The Board finds that all necessary development has been accomplished. In addition to the evidence discussed above, the Veteran's statements in support of the claim are also of record. The Board has carefully considered such statements and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For these reasons, the Board finds that the duties to notify and assist the Veteran in the development of this claim have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Initial Rating for Mood Disorder Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2013). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's appeal for a higher initial rating for a mood disorder is an appeal from the initial assignment of a disability rating in August 2006. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). Subsequently, through decisions in September 2009 and February 2012, mood disorder evaluation was staged to 50 percent, effective May 19, 2007, and then staged again to 100 percent, effective February 25, 2011. Here, the disability has not significantly changed during the initial rating period on appeal and a uniform evaluation is appropriate for the reasons indicated below. The Veteran was granted service connection for an acquired psychiatric disorder, now referred to as "mood disorder," in the August 2006 rating decision on appeal. The Veteran was initially assigned a 30 percent evaluation, effective February 1, 2006, the day after separation from active service. The RO subsequently granted an increased rating to 50 percent, effective May 19, 2007, in a July 2007 statement of the case, and a 100 percent rating, effective February 25, 2011, in a February 2012 decision. The Veteran's mood disorder is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code (DC or Code) 9435 (2013). Under this General Rating Formula, a 30 percent evaluation is provided for on evidence of 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, and recent events). Id. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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. Id. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); or the inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for 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; or memory loss for the names of close relatives, own occupation, or own name. Id. In evaluating the Veteran's level of disability, the Board has considered the Global Assessment of Functioning (GAF) scores as one component of the overall disability picture. GAF is a scale used by mental health professional and reflects psychological, social, and occupational functioning on a hypothetical continuum of mental health illness and is relevant in evaluating mental disability. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). During the initial rating period on appeal the Veteran has been assigned GAF scores between 65 and 25. GAF scores in the range of 61 to 70 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 has some meaningful interpersonal relationships. Id. Scores in the range of 41 to 50 represent 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). Id. Finally, GAF scores ranging from 21 to 30 reflect behavior that 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). Id. The VA Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501 (West 2002); 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002) (holding that "the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment"). The Board has reviewed all of the lay and medical evidence in the claims folder and finds that the Veteran is competent to report many of the symptoms and impairments associated with service-connected mood disorder including symptoms which are observable such as poor sleep, anger, suicidal ideation, feelings of anxiety, social isolation, and difficulty in work environments. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (holding that lay statements may serve to support a claim by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability that are susceptible of lay observation). The Board has not discounted any lay evidence regarding the severity of the mood disorder merely because it is lay evidence or because it was reported by the Veteran. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (holding that a history given by a veteran that has not been found by the Board to be inaccurate is not a basis for discounting an opinion based on that history). That being said, the Board has an obligation to determine the credibility of all evidence, lay and medical. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the duty to assess the credibility and weight to be given to the evidence). The Veteran contends that service-connected mood disorder has been more than 30 percent disabling prior to May 19, 2007 and more than 50 percent disabling prior to February 25, 2011. Specifically the Veteran has endorsed difficulty adapting to stressful circumstances, poor sleep, anxiety, anger, and panic attacks more than once a week. To the extent that these are observable symptoms, the Veteran's endorsements are competent. Davidson, 581 F.3d 1313; Jandreau, 492 F.3d 1372. After reviewing the entire claims file, the Board finds that the weight of the lay and medical evidence demonstrates that the Veteran's mood disorder has more nearly approximated the criteria for a 50 percent rating throughout the entire initial rating period on appeal. The Board finds that the Veteran's mood disorder has been productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as a flattened affect; stereotyped speech; panic attacks; impairment of concentration; suicidal ideation; disturbances of motivation and mood; and difficulty in maintaining effective social relationships. On VA treatment in October 2006, the Veteran presented for evaluation of depression, insomnia and headaches. The Veteran endorsed difficulty falling asleep, and that once asleep he wakes up in two to three hours "out of the blue." The Veteran admitted to a depressed mood most of the time, with feelings of worthlessness, decreased appetite, unintentional ten-pound weight loss in the past four months, insomnia, psychomotor retardation, fatigue, difficulty concentrating, and suicidal ideation every day. The suicidal ideation had begun four months prior, but the Veteran had also attempted to overdose on Tylenol 3 in 2004. The Veteran denied homicidal ideation because of not wanting to do anything "to jeopardize people on the street." On VA examination in May 2006, the Veteran's mood appeared to be depressed, and affect was decreased in range and intensity, but appropriate to immediate thought content. Speech was quiet and normal in rate, although it was somewhat difficult to engage the Veteran in conversation. Panic attacks were absent, although the Veteran reported experiencing one limited instance of an attack in 2004 which included shortness of breath, increased heart rate, nausea, and sweating. The event occurred suddenly and lasted for 30 minutes. There was no difficulty understanding complex commands. The evidence did not show short- or long-term memory impairment. On limited testing at the May 2006 VA examination, the Veteran recalled 4 of 4 words immediately. After several minutes he recalled 3 of 4 words without prompting and the fourth with prompting. Thoughts were coherent, logical, and goal directed, and impaired judgment was absent. The Veteran reported being easily irritated, and felt that this affected family relationships, though the Veteran had a brother in the area and enjoyed socializing with his sibling. The Veteran felt as if people avoided him because of irritability and depression. However the Veteran was attending college classes and reportedly completing four classes that semester. The Veteran stated a preference for being alone. Although not working at the time, the Veteran reported difficulty concentrating at work. The Veteran's GAF score was 54. VA treatment notes from November 2006 indicate that the Veteran's mood was "tired," and affect was mood-congruent and constricted. The Veteran's speech was normal. The Veteran's thought processes were linear, insight was fair, and judgment was good. The Veteran's mood was described as "tired." The Veteran was experiencing suicidal ideation "less often," and he indicated that thoughts of his children prevented acting on such ideation when such thoughts occurred. On VA examination in May 2007, the Veteran reported a history of suicidal ideation, but no current suicidal plans. Hygiene and appearance were normal, speech was normal, orientation was normal, and the Veteran denied panic attacks. The Veteran reported experiencing road rage, and being mean to family and other people. The Veteran did not get along with his supervisor, but stated that he pretended to like her. To that end, the examiner noted that the Veteran had problems establishing and maintaining work relationships - social relationships were also diminished. GAF score was 60 to 65. August 2007 VA treatment notes indicate daily suicidal ideation, but without any suicidal acts. The Veteran endorsed having a depressed mood on most days. The Veteran was fairly groomed. The Veteran's GAF score was 50, but the highest GAF score from the previous 12 months was reportedly 80. VA treatment in September 2007 reflects fair dress and grooming, with a haggard, tired look. The Veteran gave good cooperation and eye contact, with little spontaneous movement. Mood was "alright," and affect was constricted and mildly reactive. The Veteran had no desire to harm himself or others and GAF score was 25. A June 2008 VA treatment note indicates a history of suicidal ideation occurred in 2003. In June 2008, however, the Veteran had no desire to hurt himself and denied suicidal ideations. The Veteran had a normal rate and rhythm of speech, and was oriented to person, place, and time. The Veteran's dress and grooming were fair, and the Veteran described his mood as "alright." GAF was 25. A September 2008 letter from the Veteran's wife states that the Veteran would suddenly shout at her or the children without apparent reason, and that the Veteran had become irritable and mean. However, there is no indication that the Veteran acted out these frustrations physically. On VA examination in July 2009 the Veteran reported passive thoughts of death, and being unafraid to die. An absence of obsessional rituals was specifically noted by the examiner. The Veteran's speech was normal, although the rate was slow, and the Veteran's orientation was within normal limits. The Veteran stated that symptoms were intermittent, with "attacks" several days a week, lasting for one day. The Veteran reported experiencing anxiety, including panic attacks which occurred once a week, and symptoms including shakiness, feeling angry, feeling afraid, and wanting to get away. The Veteran's relationship with his three children was good, but sometimes they told him he was rude to them. The Veteran reported getting extremely angry or frustrated at times; for example being cut off in traffic made him angry to the point of wanting to run the other driver over. The July 2009 VA examiner noted that the Veteran's appearance and hygiene were mildly impaired, as demonstrated by partially shaven beard and unkempt hair. However, the Veteran was dressed appropriately and cleanly. The examiner explained that this partial neglect of appearance was likely due to a lack of motivation to complete hygiene tasks when particularly depressed. Thus, while that examination report noted neglect of some aspects of hygiene and appearance, the weight of the evidence demonstrates that hygiene was appropriate and normal. At the time of the July 2009 VA examination, the Veteran had held the same job for two years and appeared to have satisfactory performance there, reporting a fair relationship with supervisor and coworkers. The Veteran reported being very withdrawn from family, preferring to be alone in his room when home. The Veteran endorsed difficulty interacting with coworkers. Although the Veteran had been married since 1988, and stated that the relationship with his wife was fair to poor, the Veteran explained that their children kept them together. The Veteran and his wife effectively lived "separate lives" and seldom talked to each other. Nonetheless, the Veteran occasionally spent time with his brother and went to church with family members. The VA examiner concluded that the Veteran had difficulty establishing and maintaining effective work and social relationships, as indicated by reports of being withdrawn, the preference to be alone, and the Veteran's anger and irritability. GAF score was 68. In a VA nursing note of February 2010, the Veteran endorsed feeling down, depressed or hopeless for "several days," and feeling constantly on guard, watchful or easily startled. The Veteran denied a loss of interest or pleasure in doing things, and denied nightmares and feelings of numbness or detachment from others. A VA mental health note of the same month indicated that the Veteran was seen on concerns of possible suicidal ideation and thinking that "it would be better to stop [the Veteran's] stress/suffering by ending [the Veteran's] life." These were fleeting thoughts that were buffered by protective factors such as thinking about the Veteran's children and family, and the Veteran had no plan or intent related to suicide. The Veteran's stressors included work, where he had received a promotion 1 year prior, and his marriage. The Veteran endorsed trouble with sleep, feelings of guilt, low energy levels, and sexual issues. The Veteran denied any problems with appetite or concentration, episodes of mania, hallucinations and delusions. GAF score was 55. On VA behavioral health intake in August 2010, the Veteran endorsed a depressed mood, losing interest in things he had liked, irritability, being "cranky," and wanting to be alone. The Veteran also indicated feelings of helplessness/ hopelessness, lack of motivation, difficulty concentrating, fatigue, insomnia or hypersomnia, feelings of guilt "for what [the Veteran has] done to [his] wife and not being there for [his] children." Particularly noteworthy, the Veteran endorsed suicidal ideation the preceding May, and admitted to fleeting passive suicidal ideation off and on over the prior few years. Affect was appropriate to mood and content, but restricted. Insight, attention, and judgment were good to fair. GAF score was 52. On VA mental health treatment in January 2011, the Veteran indicated being "the same" as when previously seen. The Veteran had difficulty with sleep and denied current homicidal or suicidal ideation, hallucinations and delusions. Concentration was poor, psychomotor symptoms were normal, speech was slow and low. Eye contact was fair, and mood was flat but congruent. The Veteran was fully oriented, with fair insight and judgment. GAF score was 52. Based on the foregoing, the Board finds that a 50 percent initial evaluation, but not more is warranted throughout the initial rating period on appeal from February 1, 2006 through February 24, 2011. Again, the 30 percent rating currently assigned for the period prior to May 19, 2007 contemplates evidence of 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, and recent events). 38 C.F.R. § 4.130. The 50 percent rating currently assigned for the period from May 19, 2007 through February 25, 2011 contemplates evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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. Id. In order for the Veteran's service connected mood disorder to warrant a 70 percent rating, the record must show occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); or the inability to establish and maintain effective relationships. Id. Throughout the entire initial rating period on appeal, the Veteran's symptoms have been essentially consistent and have included signs of social impairment due to isolating behavior, disturbances in motivation, irritability, depressed mood, and difficulty maintaining relationships, especially with his immediate family. The Veteran's speech has been described alternatively as quiet and slow, but has more often been normal, and at least once the Veteran endorsed weekly panic attacks. Additionally, the Veteran's affect has been variously reported to be decreased, restricted and flattened. Nonetheless, the Veteran has consistently denied near constant panic attacks, obsessional rituals, and spatial disorientation, while showing no deficiency in judgment, thinking or orientation. Based on the foregoing, the Veteran's symptoms have most closely reflected the criteria for a 50 percent rating throughout the initial rating period from February 1, 2006 through February 23, 2011. The weight of the evidence demonstrates that the Veteran's GAF scores, which have been predominately between 50 and 55. The evidence does show that GAF scores have been as high as 80, and as low as 25. With regard to GAF scores of 25, assessed in September 2007 and June 2008, the Board finds have little probative value. Viewed in isolation, a GAF score of 25 would indicate behavior 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). See Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). Here, however, the Veteran's GAF scores of 25 are accompanied by clinical notes which are entirely inconsistent with such a score. VA treatment in September 2007 and June 2008 reflects that the Veteran had no delusions or hallucinations; neither communication nor judgment were impaired, and the Veteran demonstrated a clear ability to function without signs such as saying in bed all day, unemployment, and a lack of home or friends. Therefore, the Board finds that the 25 GAF s score is outweighed by higher GAF scores which are based on an accurate assessment of the Veteran's symptoms. The Veteran's GAF scores throughout the rest of the period on appeal have been between 65 and 52, with an August 2007 VA treatment record reflecting GAF scores of 80 in the prior 12 months. A GAF score of 80 would indicate an absence or minimal symptoms, see id., which the record demonstrates does not accurately reflect the Veteran's overall level of symptomatology. Nonetheless, the remaining GAF scores reflect mild to serious symptoms, ranging from depressed mood and mild insomnia, some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful relationships - GAF score of 65 - to suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job) - GAF score of 50. Id. Such level of symptomatology is most consistent with the criteria for a 50 percent rating under DC 9435. See 38 C.F.R. § 4.130. The Board is aware that the Veteran has, on multiple occasions, endorsed suicidal ideation - one hallmark of a GAF score between 21 and 30. The record reflects that this is the only such symptom of the Veteran's psychiatric disorder which is consistent with such a low score. With regard to the Veteran's history of suicidal ideation, the Board finds the Veteran's endorsements of such thoughts to be credible to the extent that he has been essentially consistent in reporting that suicidal thoughts have come and gone throughout the period on appeal. Suicidal ideation is one of the criteria of a 70 percent rating, and the Board has considered whether the Veteran's endorsements of suicidal ideation warrant a 70 percent rating for part, or all of the initial rating period. However, the Board finds that the weight of the lay and medical evidence does not demonstrate that a 70 percent rating is warranted at any time for reasons discussed below. In order to fully comply with the rating criteria the Board is not required "to find the presence of all, most, or even some, of the enumerated symptoms" indicated in 38 C.F.R. § 4.130. Mauerhan, 16 Vet. App. at 442. However, in determining the appropriate evaluation, the Board is to "consider all symptoms of a claimant's condition that affect the level of occupational and social impairment." Id. at 443. Here, the Board's consideration of the Veteran's occupational and social impairment contemplates the entire disability picture, not merely a single facette or single symptom. Thus, the Board recognizes the Veteran's suicidal ideation, and the two GAF scores of 25, but finds them not to be dispositive of the Veteran's appropriate evaluation to be assigned. Furthermore, to the extent that a staged rating to higher than 50 percent may be warranted when these symptoms are present, but Board notes that the periods when the Veteran's GAF score was assessed at 25, corresponds to periods when the Veteran did not have suicidal ideation. Thus at no time has the Veteran's total level of social and occupational impairment approximated the scheduler criteria contemplated by a 70 percent rating for service-connected mood disorder. Rather the Board concludes that the Veteran's service-connected mood disorder has been 50 percent disabling throughout the entire initial rating periods on appeal. All evidence has been considered and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Consideration The Board has also considered whether referral for an extraschedular rating is warranted for the service-connected mood disorder. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here the schedular rating criteria used to rate the Veteran's service-connected disability above, reasonably describe and assess the Veteran's disability level and symptomatology. The criteria rate the disability on the basis of occupational and social impairment thus, the demonstrated manifestations - namely irritability, self-isolation, difficulty adapting to stressful circumstances, poor sleep, anxiety, anger, and panic attacks which affect the Veteran's ability to function in work and social situations - are contemplated by the provisions of the rating schedule. As the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate. The schedular rating criteria, Diagnostic Code 9435, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, the evidence adequately reflects the symptoms of the Veteran's mood disorder include impaired sleep, anxiety, isolation, difficulty concentrating, suicidal ideation, depressed mood, and irritability. These symptoms are part of or similar to symptoms listed under the schedular rating criteria. The schedular rating criteria include occupational and social impairment, as indicated by reduced reliability and productivity, and as caused by specific psychiatric symptoms. The schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, at 442 ; see also 38 C.F.R. § 4.21 (2013). Additionally, the Board has considered GAF scores, which are incorporated through the DSM-IV as part of the schedular rating criteria, as reflective of the degree of severity of psychiatric symptoms or overall functional impairment caused by the acquired psychiatric disorder. For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's mood disorder due to cardiac arrest, with depressive-like episodes, and referral for consideration of an extra-schedular evaluation is not warranted. Finally, the record does not reveal that the Veteran is rendered unemployable by virtue of his mood disorder, and the Board finds that the record has not raised an implied claim for a total disability rating based on individual unemployability due to service-connected disabilities pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009); thus no discussion or remand of such a claim in warranted. ORDER An initial rating of 50 percent, and no higher, for mood disorder due to cardiac arrest, with depressive-like episodes is granted from February 1, 2006 through February 24, 2011. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs