Citation Nr: 1335541 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 07-25 471 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for adrenal insufficiency (Addison's disease). 2. Prior to May 3, 2008, entitlement to a disability rating in excess of 10 percent for depression. 3. From May 3, 2008 to February 24, 2012, entitlement to a disability rating in excess of 30 percent for depression. 4. From February 24, 2012, entitlement to a disability rating in excess of 70 percent for depression. 5. Entitlement to a disability rating in excess of 10 percent for hypothyroidism. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1983 to June 1983 and from April 2003 to July 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from two rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. An August 2006 rating decision continued the 10 percent disability rating for hypothyroidism and the 20 percent disability rating for adrenal insufficiency. A June 2007 rating decision granted service connection for depression and assigned an initial 10 percent disability rating. This case was previously before the Board in November 2011, at which time the Board remanded the Veteran's claims in order to obtain outstanding treatment records and to provide the Veteran with additional examinations. Additional treatment records were obtained, and the Veteran received additional VA examinations in February 2012 and May 2012. The Board finds that there has been substantial compliance with the remand instructions. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). An August 2012 rating decision granted a 30 percent disability rating for depression effective May 3, 2008, and a 70 percent disability rating effective February 24, 2012. The issue of an increased rating for depression remains on appeal because these increased ratings do not represent the highest possible benefit during the period on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The Board's November 2011 Remand also remanded the issue of entitlement to a total disability evaluation based on individual unemployability due to a service-connected disability (TDIU). While on remand, the August 2012 rating decision granted a TDIU effective February 24, 2012. When an appealed claim is granted during the pendency of the appeal, a second Notice of Disagreement must then be timely filed to initiate appellate review of "downstream" issues such as the effective date of the grant. In other words, the grant of TDIU during the pendency of the appeal has extinguished the issue before the Board, and it is no longer in appellate status before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The issue of entitlement to a disability rating in excess of 10 percent for hypothyroidism is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. Prior to February 23, 2012, the Veteran's adrenal insufficiency is manifested by symptoms producing no Addisonian crises or Addisonian episodes during any one-year period of time. 2. From February 23, 2012, the Veteran's adrenal insufficiency is manifested by symptoms producing no more than one Addisonian crisis and five or more Addisonian episodes during a one-year period of time. 3. Prior to May 3, 2008, the Veteran's depression is manifested by no more than occupational and social impairment due to mild or transient symptoms. 4. From May 3, 2008 to February 24, 2012, the Veteran's depression is manifested by no more than occupational and social impairment with reduced reliability and productivity, due to such symptoms as a blunted affect, panic attacks, impairment of memory, impairment of abstract thinking, and disturbances of motivation and mood. 5. From February 24, 2012, the Veteran's depression is manifested by no more than occupational and social impairment with deficiencies in most areas, due to such symptoms as suicidal ideation, panic attacks, near-continuous depression, difficulty in establishing and maintaining effective work and social relationships, and difficult in adapting to stressful circumstances. CONCLUSIONS OF LAW 1. Prior to February 23, 2012, the criteria for a disability rating in excess of 20 percent for adrenal insufficiency have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7911 (2012). 2. From February 23, 2012, the criteria for a disability rating of 40 percent, but no greater, for adrenal insufficiency have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7911 (2012). 3. Prior to May 3, 2008, the criteria for a disability rating in excess of 10 percent for depression have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). 4. From May 3, 2008 to February 24, 2012, the criteria for a disability rating of 50 percent, but no greater, for depression have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). 5. From February 24, 2012, the criteria for a disability rating in excess of 70 percent for depression have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim decided herein. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000) (Board must address reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duties to Notify and Assist VA has a duty to notify a Veteran as to the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). VA also has a duty to assist Veterans in the development of claims. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012). Upon receipt of a substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence that (1) is necessary to substantiate the claim; (2) VA will seek to provide; and (3) the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). An April 2006 letter provided the Veteran with all required notice, and the Board finds that no further notice is required in this case. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). The Veteran's service treatment records have been associated with the claims file. All identified and available treatment records have been secured, which includes VA treatment records, private medical records, and VA examination reports. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not show the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran was provided with VA examinations addressing his adrenal insufficiency in March 2006 and February 2012. The Veteran was provided with VA psychiatric examinations in April 2007, May 2008, and February 2012. The examination reports indicate that the examiners recorded the Veteran's current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board concludes that the examination reports are adequate to make a decision in this appeal. 38 C.F.R. § 4.2 (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). In April 2008, the Veteran presented testimony before a Decision Review Officer at the RO, and a transcript of this hearing has been associated with the record. The Veteran declined the opportunity to present testimony before a Veterans Law Judge. The Board observes that all due process concerns have been satisfied. 38 C.F.R. § 3.103 (2012). Accordingly, the Board will proceed to a decision. Increased Ratings Generally Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When there is a question as to which of two ratings shall be applied, the higher rating 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 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2012); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same manifestation of a disability under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2012). Increased Rating for Adrenal Insufficiency The Veteran contends that his adrenal insufficiency warrants a greater rating than the current 20 percent evaluation. Historically, the Veteran developed pituitary apoplexy in April 2003 and was subsequently diagnosed with a pituitary tumor. The Veteran underwent a trans-sphenoidal pituitary surgery as a result. According to a March 2006 letter from the Veteran's endocrinologist, the Veteran suffers from a history of complete anterior pituitary hormone deficiency as a result of this condition. The Board notes that the symptoms associated with this hormone deficiency are rated under a number of Diagnostic Codes, only one of which-adrenal insufficiency-is addressed in this analysis. The Veteran's pituitary macroadenoma with pituitary apoplexy is rated under Diagnostic Code 8099-8009, which applies to hemorrhage from blood vessels in the brain. The Veteran's hypogonadism due to panhypopituitarism is rated under Diagnostic Code 7915-7523, which applies to atrophy of the testis. The Veteran's hypertension is rated under Diagnostic Code 7101, applicable to hypertensive vascular disease. The Veteran's hypothyroidism due to panhypopituitarism, addressed in the Remand section below, is rated under Diagnostic Code 7903, applicable to hypothyroidism. Lastly, and the subject of the following analysis, the Veteran's adrenal insufficiency is rated under Diagnostic Code 7999-7911, applicable to Addison's disease. Accordingly, the Board observes that while there are a number of different manifestations of the Veteran's pituitary hormone deficiency, this analysis considers only those symptoms associated with the Veteran's adrenal insufficiency. Addison's disease, or adrenal insufficiency, is a chronic type of adreno-cortical insufficiency, characterized by symptoms including hypotension, weight loss, anorexia, weakness, and bronze-like hyperpigmentation of the skin, which is due to an autoimmune or tuberculosis-induced destruction of the adrenal cortex, which results in deficiency of aldosterone and cortisol, and it is fatal in the absence of replacement therapy. Dorland's Illustrated Medical Dictionary 535 (31st ed. 2007). An Addisonian "crisis" consists of the rapid onset of peripheral vascular collapse (with acute hypotension and shock), with findings that may include: anorexia; nausea; vomiting; dehydration; profound weakness; pain in abdomen, legs, and back; fever; apathy, and depressed mentation with possible progression to coma, renal shutdown, and death. 38 C.F.R. § 4.119, Diagnostic Code 7911 at Note (1). An Addisonian "episode" is a less acute and less severe event than an Addisonian crisis and may consist of anorexia, nausea, vomiting, diarrhea, dehydration, weakness, malaise, orthostatic hypotension, or hypoglycemia, but no peripheral vascular collapse. Id. at Note (2). The criteria for rating disability due to Addison's disease (adrenal cortical hypofunction) provide for a 20 percent rating for one or two crises during the past year, or two to four episodes during the past year, or weakness and fatigability, or corticosteroid therapy required for control. A rating of 40 percent applies to three crises during the past year, or five or more episodes during the past year. A 60 percent rating applies to four or more crises during the past year. 38 C.F.R. § 4.119, Diagnostic Code 7911 (2012). The Veteran underwent a VA examination in March 2006. The examiner noted that the Veteran's condition had a stable course since onset, and the Veteran had experienced a good response to prednisone therapy. The Veteran experienced frequent fatigability, occasional diarrhea, and he felt hot and cold frequently. While the examiner considered these symptoms, the examiner did not distinguish which symptoms were attributable to the Veteran's hypothyroidism and which symptoms were attributable to the Veteran's adrenal insufficiency. The Veteran's muscle strength was normal, there was no skin hyperpigmentation, and the Veteran had not experienced crises or episodes. Corticosteroid therapy was required for control, and the Veteran had experienced episodes of dehydration due to the condition. The Veteran's condition would have no effect on his ability to engage in traveling, feeding, bathing, dressing, toileting, or grooming. The condition would have a mild effect on his ability to engage in chores or shopping. The condition would have a severe effect on his ability to engage in exercise, sports, and recreation. In March 2006, the Veteran's endocrinologist provided a letter describing the treatment for the Veteran's pituitary hormone deficiency generally. The endocrinologist did not specifically describe the symptomatology associated with the Veteran's adrenal insufficiency. Instead, the endocrinologist noted generally that the Veteran experienced gastrointestinal symptoms of diarrhea alternating with depression, musculoskeletal problems with joint pain, stiffness, and fatigue, cold and heat intolerance, and a reduction in exercise tolerance. The endocrinologist noted that the Veteran was "doing a lot better on his full hormone replacement," and the Veteran had symptoms in keeping with adrenal insufficiency about two years ago, before he was started on replacement. In January 2008, the Veteran's private endocrinologist noted that the Veteran felt "good overall with regards to his hormone replacement." The Veteran underwent a VA examination in February 2012. The examiner noted that the Veteran required corticosteroid therapy for control of his condition, and he had weakness and fatigability. The Veteran had experienced one Addisonian crisis in the past 12 months, and more than five Addisonian episodes in the last 12 months. Turning to an evaluation of this evidence of record, the Board notes that the Veteran is currently in receipt of a 20 percent rating for Addison's disease. As noted above, a disability rating in excess of 20 percent requires at least three Addisonian crises in a year, or five or more Addisonian episodes in a year. Until the Veteran's February 23, 2012 VA examination, the medical evidence of record does not support such a finding. In March 2006, the Veteran had never experienced an Addisonian episode or crisis. Also in March 2006, the Veteran's private endocrinologist noted that the Veteran was doing well on hormone replacement, and that he had not experienced symptoms associated with adrenal insufficiency for two years. Indeed, the Board observes no evidence that the Veteran suffered from Addisonian crises or episodes until the February 23, 2012 VA examination, at which time the examiner indicated that the Veteran had experienced one Addisonian crisis and more than five Addisonian episodes in the last 12 months. Such a finding is consistent with a 40 percent evaluation of Addison's disease, which is associated with experiencing five or more Addisonian episodes in a year. Accordingly, the Board finds that a 40 percent rating for Addison's disease is warranted from February 23, 2012. Increased Rating for Depression The Veteran contends that his depression warrants a greater rating than the currently-staged evaluation of 10 percent prior to May 3, 2008, 30 percent from May 3, 2008 to February 24, 2012, and 70 percent from February 24, 2012. Under the General Rating Formula for Mental Disorders, a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms that decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is assigned for occupational and social impairment with occasional decreases 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). A 50 percent rating is assigned for 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 establishing effective work and social relationships. 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 that 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); and an inability to establish and maintain effective relationships. 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 and place; memory loss for names of close relatives, own occupation or name. 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency must assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). Furthermore, the Board notes that the specified factors for each incremental rating are examples, rather than requirements, for a particular rating. The Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating criteria. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Also relevant to the Board's analysis is the Global Assessment of Functioning (GAF) score assigned to the Veteran, which is a scale that indicates the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV); 38 C.F.R. § 4.130 (2012). While the veteran's GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when assigning the appropriate disability rating for the veteran. VAOPGCPREC 10-95 (1995), 60 Fed. Reg. 43186 (1995). GAF scores ranging from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally a person with such scores is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 indicate 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). American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994); 38 C.F.R. § 4.130 (2012). Analysis - Prior to May 3, 2008 After a thorough review of the evidence, the Board finds that prior to May 3, 2008, the totality of the evidence indicates that the impact of the Veteran's depression on his social and industrial functioning is most congruent with the currently-assigned 10 percent rating. Turning to the evidence of record during this period, in a February 2006 private treatment record, the Veteran complained of depression and insomnia. The Veteran underwent a VA examination in April 2007, at which time the Veteran reported that he was married and had five children. The Veteran was alert, oriented, properly groomed, and he was a good historian. The Veteran had no unusual motor behavior. The Veteran's affect was appropriate, his mood was depressed, and he had no unusual thought process or content. The Veteran denied experiencing hallucinations, and his cognition was grossly intact. The examiner diagnosed the Veteran with depressive disorder, and the examiner assigned a GAF score of 61. In February 2008, the Veteran indicated that he had difficulty managing his feelings of anger during group therapy sessions. The Veteran was alert and oriented to time, place, person, and situation. The Veteran did not display a thought disorder, and his attention span was intact. The Veteran's mood was euthymic with congruent affect. The Veteran had no suicidal ideation. Upon review of this evidence, the Board concludes that the Veteran's overall disability picture does not approximate the criteria for a 30 percent rating during this time. A 30 percent rating is assigned for occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. While mindful that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has met or approximated one of the symptoms listed as demonstrative of a 30 percent rating during this time: a depressed mood. The Veteran showed no anxiety, suspiciousness, panic attacks, chronic sleep impairment, or memory loss during this time. Therefore, because the record does not show such symptoms resulting in occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, a 30 percent disability rating is not appropriate during this time. Similarly, the Veteran's overall disability picture does not more nearly approximate the criteria for a 50 percent rating during this time. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity. While mindful that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has met or approximated only one of the symptoms listed as demonstrative of a 50 percent rating during this time: a disturbance of mood in the form of depression. The Veteran showed none of the other symptoms associated with a 50 percent disability rating, such as a flattened affect, impaired speech, panic attacks, difficulty in understanding complex commands, impairment of memory, impaired judgment, impaired abstract thinking, or difficulty in establishing or maintaining effective work and social relationships. Therefore, a 50 percent disability rating is not appropriate during this time. Similarly, the Board concludes that the Veteran's overall disability picture does not more nearly approximate the criteria for a 70 percent rating during this time. 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. While mindful that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has met or approximated one of the symptoms listed as demonstrative of a 70 percent rating during this time: in May 2008, the Veteran indicated that he experienced suicidal ideation sometime in 2007. The Veteran showed no obsessional rituals, impaired speech, near-continuous panic or depression affecting the ability to function, impaired impulse control, disorientation, neglect of hygiene, difficulty adapting to stressful circumstances, and an inability to establish and maintain effective relationships. Therefore, notwithstanding the Veteran's later suggestion that he once experienced suicidal ideation during this time, a 70 percent disability rating is not appropriate. Similarly, the Board concludes that the Veteran's overall disability picture during this time does not more nearly approximate the criteria for a 100 percent rating. A 100 percent rating is assigned for total occupational and social impairment. The evidence does not demonstrate that the Veteran presented a persistent danger of hurting himself or others. The record shows no evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, or grossly inappropriate behavior. The Veteran did not show an intermittent inability to perform activities of daily living, disorientation to time and place, or memory loss for the names of close relatives, his own occupation, or his own name. Therefore, a 100 percent disability rating is not appropriate during this time. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of sadness associated with depression. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a competent and persuasive opinion on a medical matter, especially the severity of his psychiatric disability in terms of the applicable rating criteria and its effect on his ability to work. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, that necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. In making this determination, the Veteran's GAF score of record has been considered. The Veteran was assigned a GAF score of 61 during his April 2007 VA examination. The Board finds that this score, which is indicative of symptoms of mild severity, is not consistent with the assignment of a disability rating in excess of the currently-assigned 10 percent evaluation. In sum, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 10 percent for depression prior to May 3, 2008. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis - From May 3, 2008 to February 24, 2012 After a thorough review of the evidence, the Board finds that from May 3, 2008 to February 24, 2012, the totality of the evidence indicates that the impact of the Veteran's depression on his social and industrial functioning is most congruent with a 50 percent rating, rather than the currently-assigned 30 percent rating. Turning to an evaluation of the medical evidence of record, the Veteran underwent a VA examination on May 3, 2008, at which time the Veteran reported that he felt depressed at least four days weekly. The Veteran no longer enjoyed activities that he once did, such as watching movies and attending alumni events. The Veteran reported experiencing difficulty falling asleep and maintaining sleep, and he felt consistently tired. The Veteran had a decreased appetite, and he had problems with concentration. The Veteran reported having thoughts of suicide, with his last suicidal thought occurring in 2007. The Veteran endorsed feelings of hopelessness, guilt, and worthlessness. The Veteran indicated that he experienced panic attacks that caused problems with his driving. The examiner observed the Veteran to be clean, neatly groomed, and appropriately dressed. The Veteran was cooperative, and his speech and psychomotor activity were normal. The Veteran's affect was normal, and his mood was depressed. The Veteran was unable to perform serial 7s or spell a word forward and backward. The Veteran was oriented, and his thought process and thought content were unremarkable. The Veteran was not delusional, and he understood the outcome of his behavior. The Veteran's intelligence was above average, and the Veteran's insight was appropriate. The Veteran had a sleep impairment. The Veteran did not exhibit inappropriate behavior. The Veteran experienced panic attacks at least once weekly, with each panic attach lasting from 30 to 60 minutes. The Veteran had no homicidal thoughts or episodes of violence. The Veteran's remote memory was mildly impaired, his recent memory was severely impaired, but his immediate memory was normal. The examiner diagnosed the Veteran with depression and assigned the Veteran a GAF score of 52. The examiner indicated that the Veteran did not exhibit total occupational and social impairment due to his mental disorder. The examiner found that the Veteran's mental disorder resulted in deficiencies in thinking, family relations (for example, isolating from his children and being more irritable with his spouse), mood, and school. The mental disorder did not result in deficiencies in judgment. In October 2010, a VA clinician noted that the Veteran had been referred for individual psychotherapy to address the depression associated with his chronic health problems and "friction" in his relationships with extended family. The Veteran experienced decreased interest, increased irritability, and sadness. The Veteran reported having strained relationships with his siblings following the death of his father. The clinician observed that the Veteran was casually dressed, alert, fully oriented, and he did not exhibit a thought disorder. The Veteran's mood was euthymic with a blunted affect. The Veteran was not in acute emotional distress, and he denied suicidal and homicidal ideation. The Veteran's insight and judgment were intact. The clinician assigned the Veteran with a GAF score of 65. Later in October 2010, a VA clinician noted that the Veteran was alert and fully oriented. The Veteran's mood was euthymic with a congruent affect. The Veteran was in no acute emotional distress, and he did not express suicidal thoughts. The Veteran's insight and judgment were intact. The Veteran reported a reduction in stress. Although the Veteran does not have all the symptomatology associated with the assignment of a 50 percent rating, the Board finds that the impact of the Veteran's depression on his social and occupational functioning sufficiently approximates the degree of impairment contemplated by a 50 percent rating. 38 C.F.R. § 4.7 (2012). As noted above, a 50 percent disability rating contemplates occupational and social impairment with reduced reliability and productivity. The Veteran has shown or approximated many of the symptoms associated with a 50 percent rating. The Veteran's affect in October 2010 was "blunted." The Veteran indicated that he experienced at least weekly panic attacks that affected his ability to drive safely. The Veteran demonstrated impairment of memory and impaired abstract thinking. The Veteran had disturbances of motivation and mood in the form of depression. The Veteran had difficulty maintaining effective social relationships, in the form of irritability with his spouse, isolative behavior from his children, and "friction" with his extended family. The Board finds that the Veteran's symptomatology during this time is most consistent with a 50 percent rating during this time. The Veteran's overall disability picture does not more nearly approximate the criteria for a 70 percent rating during this time. 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. While mindful that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has met or approximated none of the symptoms listed as demonstrative of a 70 percent rating during this time. The Veteran showed no suicidal ideation during this time (in May 2008, the Veteran stated that he felt suicidal in 2007), obsessional rituals, impaired speech, near-continuous panic or depression affecting the ability to function, impaired impulse control, disorientation, neglect of hygiene, difficulty adapting to stressful circumstances, or an inability to establish and maintain effective relationships. As noted above, while the Veteran complained of irritability and "friction" with his family, such difficulty does not demonstrate an inability to maintain such relationships. Therefore, upon review of this symptomatology, the Board finds that a 70 percent disability rating is not appropriate during this time. Similarly, the Board concludes that the Veteran's overall disability picture during this time does not more nearly approximate the criteria for a 100 percent rating . A 100 percent rating is assigned for total occupational and social impairment. The Veteran did not present a persistent danger of hurting himself or others. The record shows no evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, or grossly inappropriate behavior. The Veteran did not show an intermittent inability to perform activities of daily living, disorientation to time and place, or memory loss for the names of close relatives, his own occupation, or his own name. Therefore, a 100 percent disability rating is not appropriate during this time. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of sadness associated with depression. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a competent and persuasive opinion on a medical matter, especially the severity of his psychiatric disability in terms of the applicable rating criteria and its effect on his ability to work. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, that necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. In making this determination, the Veteran's GAF scores have been considered. The May 2008 examiner assigned the Veteran a GAF score of 52, and an October 2010 clinician assigned the Veteran a GAF score of 65. The Board finds that these scores, which are indicative of symptoms of mild to moderate severity, are consistent with the assignment of a 50 percent disability rating. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of sadness associated with depression. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a competent and persuasive opinion on a medical matter, especially the severity of his psychiatric disability in terms of the applicable rating criteria and its effect on his ability to work. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, that necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. In sum, the Board finds that the preponderance of the evidence supports the award of a 50 percent disability rating for depression, but no greater, from May 3, 2008 to February 24, 2012. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis - From February 24, 2012 After a thorough review of the evidence, the Board finds that from February 24, 2012, the totality of the evidence indicates that the impact of the Veteran's depression on his social and industrial functioning is most congruent with the currently-assigned 70 percent rating. Although the Veteran does not have all the symptomatology consistent with the assignment of a 70 percent rating, the Board finds that the impact of the Veteran's depression on his social and occupational functioning sufficiently approximates the degree of impairment contemplated by a 70 percent rating. 38 C.F.R. § 4.7 (2012). The Veteran underwent a VA examination on February 24, 2012, at which time the examiner diagnosed the Veteran with depression. The examiner indicated that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The examiner indicated that the Veteran suffered from a depressed mood, anxiety, panic attacks occurring weekly or less often, mild memory loss (such as forgetting names, directions, or recent events), flattened affect, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficult in adapting to stressful circumstances, including work or a work-like setting, and suicidal ideation. The examiner remarked that the Veteran's symptoms of depression appeared to have become considerably worse since the time of the last examination. The examiner assigned the Veteran with a GAF score of 55. A 100 percent evaluation is unwarranted during this time because the Veteran's symptoms do not create total occupational and social impairment. The Board observes that the Veteran has maintained a long-term relationship with his spouse throughout this period. Furthermore, the February 2012 examiner indicated that the Veteran did not suffer from total occupational and social impairment as a result of his depression. While mindful of the guidance from Mauerhan that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has not met or approximated any of the listed symptoms for a 100 percent rating. Furthermore, the Board observes that neither the Veteran nor his representative have argued that a 100 percent rating of the Veteran's PTSD is appropriate. For these reasons, the Board finds that a 100 percent rating of the Veteran's PTSD is not appropriate. In making this determination, the Veteran's GAF score has been considered. The Veteran was assigned a GAF score of 55 during his February 2012 VA examination. The Board finds that this score, which is indicative of moderate symptoms, is inconsistent with the assignment of a disability rating in excess of 70 percent. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of sadness associated with depression. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a competent and persuasive opinion on a medical matter, especially the severity of his psychiatric disability in terms of the applicable rating criteria and its effect on his ability to work. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, that necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. The Board finds that the preponderance of the evidence is against the assignment of a rating greater than 70 percent for PTSD from February 24, 2012. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Ratings The Board has also considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. The VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57 (1993). There is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Thun v. Peake, 22 Vet App 111 (2008). The Board finds that the evidence does not show such an exceptional disability picture due to the Veteran's adrenal insufficiency or psychiatric disabilities that the available schedular ratings for such disabilities are inadequate. The rating criteria for the Veteran's adrenal insufficiency and psychiatric disability reasonably describe the Veteran's disability level and symptomatology. Higher ratings are available, but the Veteran does not meet the criteria to be assigned a higher rating. Therefore, the Board finds that referral for consideration of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1) (2012). ORDER Prior to February 23, 2012, a disability rating in excess of 20 percent for adrenal insufficiency is denied. From February 23, 2012, a disability rating of 40 percent for adrenal insufficiency is granted, subject to the laws and regulations governing the award of monetary benefits. Prior to May 3, 2008, a disability rating in excess of 10 percent for depression is denied. From May 3, 2008 to February 24, 2012, a disability rating of 50 percent for depression is granted, subject to the laws and regulations governing the award of monetary benefits. From February 24, 2012, a disability rating in excess of 70 percent for depression is denied. REMAND The Veteran's claim of entitlement to a disability rating in excess of 10 percent for hypothyroidism must again be remanded. Although the Board regrets the delay associated with this remand, further development of the record is required before the Board may render a decision. Once VA provides a veteran with a medical examination, due process requires that VA notify the veteran prior to the adjudication of the claim of any inability to obtain evidence sought, including a VA examination with medical opinion. Barr, 21 Vet. App. at 311 (noting that "[o]nce VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, VA must provide an adequate one or, at a minimum, notify the [veteran] why one will not or cannot be provided"); see also Daves v. Nicholson, 21 Vet. App. 46, 51 (2007), citing Green v. Derwinski, 1 Vet. App. 121, 123-24 (1991); Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). In February 2012, the Veteran underwent a VA examination of endocrine diseases (other than thyroid, parathyroid, or diabetes mellitus). The examiner addressed the Veteran's non-thyroid endocrine conditions, but then opined that it was at least as likely as not that the Veteran, as a result of hypothyroidism, had fatigability, continuous medication required for control, constipation, mental sluggishness, cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (such as dementia, slowing of thought, or depression), bradycardia, or sleeplessness. As noted above, the examination was not a thyroid examination. In May 2012, the Veteran underwent a VA examination specifically addressing thyroid and parathyroid conditions. Contrary to the findings of the February 2012 examiner, the May 2012 examiner stated that while the Veteran's hypothyroidism required continuous medication for control, the Veteran otherwise had no findings, signs, or symptoms attributable to a hypothyroid condition, including fatigability, constipation, mental sluggishness, mental disturbance, muscular weakness, weight gain, sleepiness, cold intolerance, or bradycardia. The examiner similarly found that the Veteran did not have any findings, signs, or symptoms attributable to a hypoparathyroid condition. Upon review of this evidence, the Board observes that the February 2012 VA examiner associated a number of symptoms with the Veteran's hypothyroidism, and the May 2012 examiner found no such symptoms were associated with the Veteran's hypothyroidism. The May 2012 examiner did not address the significance, if any, of the findings of the February 2012 examiner. On remand, an addendum opinion, with the option for an additional examination, should be solicited clarifying the symptoms that the Veteran experiences as a result of his hypothyroidism, and the severity of any such symptoms. Accordingly, the case is REMANDED for the following actions: 1. Obtain copies of updated treatment records and associate them with the claims file. 2. Then, forward the Veteran's claims file to the examiner who conducted the May 2012 thyroid examination. The May 2012 examiner should review the findings of the February 2012 VA examiner indicating that as a result of hypothyroidism, the Veteran suffered from fatigability, constipation, mental sluggishness, cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (such as dementia, slowing of thought, or depression), bradycardia, or sleeplessness. The examiner is asked to reconcile his findings that the Veteran suffered from no such symptoms with the findings of the February 2012 VA examiner that the Veteran suffered from all of these symptoms. In other words, the examiner must opine why the February 2012 VA examiner found that the Veteran had all such symptoms when the Veteran demonstrated no such symptoms during the May 2012 examination. If this opinion cannot be provided without a re-examination of the Veteran, then another examination of the symptoms associated with the Veteran's hypothyroidism should be provided. If the May 2012 examiner is unavailable, then the Veteran should be provided with an additional examination with a physician of appropriate expertise in endocrinology in order to determine the current severity of the Veteran's hypothyroidism. The examiner must review the claims file and should note that review in the report. All necessary tests and studies should be conducted in order to identify and describe the symptomatology attributable to the Veteran's service-connected hypothyroidism. A complete rationale must be given for all opinions and conclusions expressed. The results of any test that is conducted, and the significance of the results, must be included in the examination report. 3. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claim. If action remains adverse to the Veteran, provide the Veteran and his representative with a supplemental statement of the case and allow them an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ____________________________________________ L. A. Rein Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs