Citation Nr: 1336356 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 08-14 398 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to an increased rating for service-connected generalized anxiety disorder (GAD), currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran had active duty service from November 1967 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) in San Juan, Puerto Rico, which raised the GAD rating from 10 to 50 percent. In May 2012, the Board remanded the appeal to obtain updated VA treatment records. Such records were obtained and the case has returned for review on the merits. A review of the Virtual VA paperless claims processing system includes updated VA treatment records. The RO considered these updated VA treatment records in the December 2012 Supplemental Statement of the Case. FINDING OF FACT The clinical signs and manifestations of the Veteran's generalized anxiety disorder more nearly approximate occupational and social impairment with reduced reliability and productivity due to sleep disturbances, anxiety over physical health, social withdrawal, irritability, and depressed mood. CONCLUSION OF LAW The criteria for a rating in excess of 50 percent rating for generalized anxiety disorder have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1- 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9400 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under the VCAA, 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. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant was must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his entitlement to increased compensation. The notice, however, required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of the specific diagnostic codes that may be considered. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). A March 2007 letter apprised the Veteran of what the evidence must show to establish entitlement to the benefit, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. It provided examples of medial and lay evidence to submit in support of the claim. The letter also notified the Veteran of the general criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA had fulfilled its duty to notify. 38 C.F.R. § 3.159(b). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained the Veteran's service treatment records (STRs) and all of the identified relevant post-service VA treatment records and private medical records. He was afforded VA psychiatric examinations in March 2007, April 2009 and March 2011 to assess the severity of his service-connected GAD. There is no indication that the Veteran's GAD has materially increased since the most recent examination. The record reflects substantial compliance with the May 2012 remand. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required). The current record includes updated VA treatment records. The agency of original jurisdiction (AOJ) re-adjudicated the claim in December 2012. The duty-to-assist requirements under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c) have been satisfied. Analysis Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). A Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, however, an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign 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. 38 C.F.R. § 4.126(a). Although VA adjudicators will consider the extent of social impairment, they shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. §§ 4.125, 4.130. Generalized Anxiety Disorder (GAD) is rated under 38 C.F.R. § 4.130, DC 9400, according to the General Rating Formula for Mental Disorders. Under the General Rating Formula, a 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, 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); inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are intended to serve as examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Federal Circuit has also recently stated that evaluation under § 4.130 is "symptom-driven" and that "a veteran may only qualify for a given disability rating under [this criteria] by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that § 4.130 "requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). As relevant, the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. A GAF score of 51-60 rating indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Although the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2012); Id. When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). For historical purposes, VA recognized the Veteran as having a service connected nervous disorder in November 1970 as related to recent combat experiences in Vietnam. He was awarded a 10 percent disability rating for his nervous disorder. VA treatment records, dated in January 2006, reflect that the Veteran had less irritability and felt more active. He denied any additional symptoms. The examiner assessed anxiety disorder and depression due to Parkinson's disease. He assigned a GAF of 75. VA treatment notes from August 2006 show a similar report. In February 2007, the Veteran filed his current claim for an increase. The Veteran had a March 2007 VA psychiatric examination. His current complaints included poor sleep, anxiety, depression, imbalance, and poor health. He had a good relationship with his wife. He believed his medications controlled his irritability and reactions. He did not engage in social activities. Mental status examination showed him to present with an appropriate appearance. He had difficulty walking and exhibited Parkinson's hand tremors. He was fully oriented. He displayed a flat affect and an anxious and depressed mood. Attention, concentration, and speech were good. He denied any hallucinations or suicidal/homicidal thoughts. He exhibited good impulse control. The examiner deemed his insight and judgment to be fair. He diagnosed Generalized Anxiety Disorder (GAD) with depressive features. A GAF of 60 was listed. VA treatment records from April 2007 show that the Veteran had a fluctuating mood. He was both frustrated and anxious over his Parkinson's symptoms of movement difficulties. He presented with a good appearance. He displayed clear, relevant, and goal directed speech. Memory was preserved. The examiner maintained the anxiety and depression diagnoses and listed a GAF of 65. In June 2007, the Veteran reported discontinuing medication due to its side effects of dizziness and nausea. He complained about difficulty concentrating. He recently had an episode of irritability. Mental status examination showed him to have a good appearance. His mood was dysthymic and he displayed a constricted affect. Speech was clear, relevant, and goal directed. Memory was preserved, but his concentration was diminished. The examiner assessed symptoms of depression, memory deficits, and impaired concentration. The anxiety and depression diagnoses were maintained, but the examiner lowered the GAF to 55. VA treatment records from September 2007 show the Veteran complaining about concentration difficulties. He had irritability and hallucinations. Mental status examination was similar to June 2007, but with the addition of visual hallucinations. The examiner continued the assessment of depression, memory deficits, and impaired concentration. He also added that the Veteran's recall for immediate memory was somewhat faulty. The examiner commented that the hallucinations were most likely due to Parkinson's disease and augmented the diagnoses accordingly. He listed a GAF of 45. In January 2008, the Veteran reported that his hallucination had become less frequent and intense. He believed his medication was beneficial. Mental status findings were similar to September 2007. The examiner maintained the anxiety and depression diagnoses, to include psychotic features, and a GAF of 45 from the September 2007 evaluation. Private medical records from March 2008 show that the Veteran had mild dementia related to Parkinson's disease. At his May 2008 VA consultation, the Veteran complained about sensory disorders. Mental status findings were substantially similar to January 2008 findings. A GAF of 45 was maintained. In January 2009, the Veteran continued to experience visual hallucinations, involuntary movements, and a depressed mood. He presented with a good appearance and had clear, goal directed speech. The examiner, however, observed a depressed mood and blunted affect. He also noted diminished concentration and "somewhat" faulty recall for immediate events. The Veteran denied homicidal/suicidal ideations. The examiner maintained the prior diagnoses of anxiety disorder and depression with psychotic features, both due to Parkinson's disease. GAF was listed as 50. Similar symptoms were found in February 2009. A Behavioral Nurse Screening from April 2009 shows that the Veteran had increased depressive and anxiety symptoms. The Veteran underwent another VA psychiatric examination in April 2009. He endorsed anhedonia, depression, loss of memory, among other similar symptoms. They had started in approximately 2001 and were described as moderate. Mental status examination showed the Veteran to present with a good appearance. However, he was tearful during the interview and displayed involuntary movements related to Parkinson's disease. The examiner described the Veteran's speech as impoverished. He displayed a constricted affect and depressed mood. His attention was intact, but he could not answer "serial 7's" or spell a word backwards and forwards. He was fully oriented to person, place, and time. His thought process was preoccupied by one or two topics. He denied hallucinations or delusions. He did not have obsessive/ ritualistic behavior, panic attacks, or homicidal / suicidal ideations. He demonstrated good impulse control. The examiner assessed the Veteran's remote and immediate memory as normal, but recent memory was mildly impaired. The examiner diagnosed GAD with depressive features. He gave a GAF of 50. He stated that the psychiatric symptoms were controlled by continuous medication. VA treatment records from June 2009 reflect that the Veteran had a medication increase in April. He continued to have fluctuating moods, memory deficits, and visual hallucinations. The symptoms observed by the treating clinician were similar to those demonstrated in January and February 2009 reports. A GAF of 50 was continued. In October 2009, the Veteran reported that he was more alert and less dysthymic. His hallucinations had stopped. However, he reported becoming more anxious when his tremor symptoms appeared. He continued to have memory problems. The examiner still observed a dysthymic mood and blunted affect. He continued the assessment of "somewhat faulty" memory recall for recent events. He assessed the Veteran as having continued anxiety symptoms with improving depressive symptoms. Memory deficits were still present. The examiner maintained the previous diagnoses, but raised the GAF to 65. VA treatment records from March 2010 show that the Veteran continued to struggle with his physical disability. He described anhedonia. He had ideas about death, but denied any suicidal ideation. He continued to have anxiety symptoms during tremor episodes. He denied any hallucinations, but affirmed memory problems. Clinical examination showed the Veteran to present with a good appearance. He exhibited a slow psychomotor response. He continued to have the previously assessed memory problems. His speech content continued to be clear, relevant, and goal directed. The examiner noted that the Veteran had had increased depressive symptoms from major depression as opposed to Parkinson's disease. No suicidal or homicidal ideations were observed. The examiner continued the previous diagnoses, but lowered the GAF to 55. In June 2010 psychiatric medication management notes, the Veteran's chief complaint was insomnia. He reported seeing images or shadows where he was unsure if they were real. Otherwise, he denied hallucinations. His wife had him decreased his medication because of increased anxiety. Mental status examination was similar to March 2010. The examiner continued the previous diagnoses and noted that insomnia could be related to his physical conditions. He raised the GAF to 60. VA treatment notes from November 2010 reflect that the Veteran had lost some weight due to decreased appetite. He had daytime somnolence. He again reported hallucination type experiences and described his mood as up and down. Mental status examination was similar to March and June 2010. The clinician adjusted the Veteran's medication regimen. He raised the GAF to 65. VA reports from February 2011 show that the Veteran was now legally blind. He continued to have visual hallucinations, but tried to ignore them. He continued to have depressive episodes; however, daytime somnolence improved after the last medication adjustment. Mental status examination was similar to March, June, and November 2010. The clinician discontinued one medication as recommended by the ophthalmologist. He maintained the prior diagnoses and GAF of 65. In his March 2011 VA consultation, the Veteran reported struggling with his physical disabilities. He continued to have visual hallucinations, but reported that they were "nice" images. His anxiety remained. Mental status examination was similar to prior findings in 2010 and February 2011. Notably, the examiner observed involuntary Parkinson's movements and slow psychomotor response. Recent and remote memory was intact. He noted diminished concentration and attention with limited insight. He instructed the Veteran to restart medication if psychotic symptoms returned. He diagnosed anxiety disorder due to medical condition and major depression, severe, with psychotic features. He maintained the GAF at 65. The Veteran also had a VA examination in March 2011. The Veteran endorsed symptoms of anxiety, irritability, sadness, crying spells, and adjustment difficulties due to chronic health problems. He described the severity as moderate to severe. Mental status examination showed the Veteran to present with an appropriate appearance. He exhibited a constricted affect and anxious mood. Speech was spontaneous, but psychomotor activity was tense. He was fully oriented to person, place, and time. Thought process and content were unremarkable. He denied psychotic symptoms and suicidal/homicidal ideations. He displayed good impulse control and hygiene maintenance. The examiner assessed remote and recent memory as mildly impaired; however, immediate memory was normal. He diagnosed GAD with depressive features and listed a GAF of 60. In February 2012, the Veteran reported that he felt better since the last adjustment of his Parkinson's medications. He still had tremor episodes, which triggered anxiety and depression, but these were becoming less frequent. His vision had improved and hallucinations had ceased. On mental status examination, the clinician noted decreased depressive symptoms. Other findings were similar to prior mental status examinations. The examiner continued the established diagnoses and maintained the GAF at 65. VA treatment notes from July 2012 show that the Veteran reported similar symptoms as in February 2012, but with the return of insomnia. Mental status examination was similar to prior findings. The examiner continued the established diagnoses, but adjusted the GAF to 60-65. In October 2012, similar findings to those made in February and July 2012 were listed in VA treatment notes. The Veteran had another medication adjustment. The established diagnoses were maintained, and the GAF was listed as 60-65. The Veteran contends that his service connected GAD symptoms are worse than those contemplated by the current 50 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9400. As detailed below, the Board finds that his GAD symptoms do not approximate the 70 percent rating criteria, and the claim must be denied. Under the general rating formula, a 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. As a threshold matter, the treating VA clinician has identified the Veteran's hallucinations as secondary to Parkinson's disease. See VA treatment records, dated September 2007, January 2008, and January 2009. When it is possible to distinguish symptoms attributable to service and non-service disabilities, the non-service connected symptoms are not considered for ratings purposes. See Mittleider v. West, 11 Vet. App. 181 (1998). Here, the Board will not consider hallucinations as being a service connected GAD symptom. Id. Throughout the claims period, the GAD symptoms do not include the following: suicidal or homicidal ideation, mood disturbance of such severity to compromise his ability to independently function, gross communication or cognitive deficits, poor impulse control, psychotic disturbances, or neglect of personal hygiene. The Veteran has maintained a relationship with his wife and exhibited cooperative behavior with treating clinicians at all times. Although he has memory and slight speech impairments, he has been able to effectively communicate with treating clinicians to facilitate medical care. His primary psychiatric symptoms are anxiety, mood disorders, irritability, insomnia, and memory deficits. It appears his GAD symptoms increased somewhat from September 2007 through March 2010. From the September 2007 notes, the examiner appears to lower the score due to the newly reported hallucinations. As explained above, the hallucinations are not service connected symptoms. Again, his primary complaints over this period include low mood, anhedonia, irritability, and memory impairment; however, the severity of these symptoms is not indicative of deficiencies in family relations, thinking, judgment, or mood. Objective clinical evaluation consistently reflects that he had good impulse control, good personal hygiene, and was able to function independently despite his mood disorders. He continued to maintain a relationship with his wife. He never endorsed suicidal or homicidal ideations due to his poor mood. The Board does not consider these GAD symptoms indicative of deficiencies in family relations, thinking, judgment, or mood, such as to support the next-higher 70 percent rating during any part of the appeals period. Overall, there is no showing of deficiencies in most areas or of an inability to establish and maintain effective relationships, such as to support the next-higher 70 percent rating at anytime over the appeals period. The criteria for a rating in excess of 50 percent for GAD have not been met. Mauerhan, 16 Vet. App at 442; Vazquez-Claudio, 713 F.3d 112; 38 C.F.R. § 4.130, DC 9400. Extraschedular considerations If the evidence raises the question of entitlement to an extraschedular rating, 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 a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). After consideration of the evidence, the Board has determined that referral for an extraschedular rating is not warranted. The Board has considered symptoms of the Veteran's service-connected GAD alone, and in conjunction with his additional service connected disabilities. Mittleider v. West, 11 Vet. App. 181 (1998). The clinical examiners have not identified any unusual or otherwise exceptional symptoms. The primary symptoms of mood disorder, anxiety, irritability, insomnia, and memory impairment are clearly contemplated by the schedular rating criteria. The record does not otherwise suggest the presence of any extraordinary symptoms or manifestations due to GAD or other service connected disabilities either considered jointly or singly. For these reasons, the Board considers the schedular evaluation to be adequate and referral for extraschedular consideration is not warranted. 38 C.F.R. § 3.321. Total disability rating based upon individual unemployability (TDIU) The Court has held that a Total Rating for Compensation Based on Individual Unemployability (TDIU) is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran filed a TDIU claim in June 2008. He reported that he had a high school education and last worked in 1998 as an electrician's assistant. He contended that his service connected GAD and gunshot wound residuals prevented him from resuming employment. In January 2001, he was awarded a non-service connected pension based upon bilateral carpal tunnel syndrome, low back disability, and neck disability, among others. VA examination reports reflect that the Veteran retired in 2000 due to Parkinson's disease and associated depression. The evidence clearly shows that the Veteran's nonservice-connected physical disabilities, and not his service-connected disabilities, render him unemployable. TDIU is not for further consideration at this time. ORDER A rating in excess of 50 percent for service-connected generalized anxiety disorder is denied. ____________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs