Citation Nr: 1338150 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 00-04 439A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUE Entitlement to an evaluation in excess of 50 percent prior to September 10, 2007, and in excess of 70 percent beginning on September 10, 2007 for the service-connected anxiety disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from April 1988 to April 1992. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a September 2004 rating decision of the RO that increased the rating assigned for the service-connected anxiety disorder to 50 percent, effective January 24, 2003 (the date of a VA examination). The Veteran appealed the rating assigned, but not the effective date. In April 2009, the Board remanded for the case for additional development of the record. In a December 2010 rating decision, the RO increased the rating for the service-connected anxiety disorder to 70 percent, effective on September 10, 2007 (the date of a VA treatment record). In March 2011, the Board again remanded the case for further development. In a March 2012 rating decision, the RO increased the rating for the service-connected anxiety disorder to 100 percent, effective on May 12, 2010 (the date of a VA treatment record). As the Veteran has not expressed satisfaction with the "stages" where his anxiety disorder was not rated 100 percent disabling, those "stages" of the appeal remain the subject of appeal. AB v. Brown, 6 Vet. App. 35 (1993). In September 2012, the Board remanded the matter on appeal for the third time for additional development. As noted in September 2012, the matter of service connection for a disability manifested by weight loss and diarrhea, including as due to an undiagnosed illness, was referred to the Agency of Original Jurisdiction (AOJ) for clarification and any appropriate action. A review of the documents contained on the Virtual VA paperless claims processing system has been performed in conjunction with this decision. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. For the period of the appeal prior to November 19, 2006, the date of a VA psychiatric examination report, the service-connected anxiety disorder is shown to have been manifested by no more than occupational and social impairment with reduced reliability and productivity; neither occupational and social impairment with deficiencies in most areas nor total occupational and social impairment was demonstrated during this initial stage of the appeal. 2. For the period of the appeal beginning on November 19, 2006, the service-connected anxiety disorder is shown to have been productive of a disability picture that more nearly approximated that of total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for the assignment of an increased evaluation in excess 50 percent prior to November 19, 2006 for the service-connected anxiety disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130 including Diagnostic Code 9400 (2013). 2. The criteria for the assignment of a rating of 100 percent beginning on November 19, 2006 for the service-connected anxiety disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130 including Diagnostic Code 9400 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2008); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the record reflects that the originating agency provided the Veteran with the notice required by VCAA and under Dingess in notice letters. The Veteran's claim was initially adjudicated, and he filed a timely appeal. Subsequently, the claim was most recently readjudicated in a September 2013 Supplemental Statement of the Case. See Mayfield v. Nicholson, 20 Vet. App. at 543; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect). Accordingly, with respect to VCAA notice, there is no prejudice to the Veteran in the Board's proceeding with a decision on the merits as to the claim for increase. Concerning VA's duty to assist, the Board notes that VA has obtained the Veteran's service personnel records, post-service VA and private treatment records, and his testimony and lay statements. VA has made reasonable efforts to obtain all available records as well as all relevant records adequately identified by the Veteran. In addition, the Veteran was afforded VA psychiatric examinations in May 2004, May 2005 and November 2006 in order to evaluate the severity of the service-connected anxiety disorder. Each examination report reflects a review of the claims file, a pertinent history, and all clinical findings and opinions necessary for proper adjudication of the Veteran's claim. VA also obtained two supplemental VA medical opinion reports in July 2013 that addressed the severity of the Veteran's symptomatology during the periods prior to September 10, 2007 and from September 10, 2007 to May 11, 2010. Each of 2013 VA medical opinion reports showed that the VA examiners reviewed the claims folder, noted the significant clinical evidence documented in the medical records, and provided medical conclusions supported by a rationale. The Board acknowledges that, in the September 2012 remand directives, the VA examiner was instructed to comment on the presence or absence of each symptom in the criteria for rating mental health; however, upon further consideration, the Board notes that such action goes beyond the role and responsibility of a medical examiner. As such, the Board finds that there has been substantial compliance with the 2012 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 104-106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). The Board also notes that the findings the examination reports and medical opinion reports are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In short, the Board in carefully considering the provisions of VCAA and the record on appeal finds that the development of the claim for increase has been consistent with the provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claims. See 38 C.F.R. § 3.103. He has retained the services of a representative, but declined to testify during a personal hearing. 2. Increased Rating Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 an evaluation 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). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran seeks a rating in excess of 50 percent prior to September 10, 2007, and in excess of 70 percent beginning on September 10, 2007 for the service-connected anxiety disorder. His disability is currently rated as 100 percent disabling under the general criteria applicable to psychiatric disabilities found at 38 C.F.R. § 4.130 including Diagnostic Code 9400. Under the criteria found at Diagnostic Code 9400, a 50 percent evaluation requires 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. 38 C.F.R. § 4.130, Diagnostic Code 9400. A 70 percent rating may be assigned where 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; obsessed 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. 38 C.F.R. § 4.130, Diagnostic Code 9400. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9400. In rating the severity of the service-connected psychiatric disability under these criteria, the Board is aware of the fact that psychiatric health care providers have their own system of ranking psychiatric disability. This is the Global Assessment of Functioning (GAF) rating scale, and it is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM- IV); Richard v. Brown, 9 Vet. App. 266, 267 (1996)(citing DSM-IV). The GAF scale score assigned does not determine the disability rating VA assigns; however, it is one of the medical findings that may be employed in that determination, and it is highly probative, as it relates directly to the Veteran's level of impairment of social and industrial adaptability. VAOPGCPREC 10-95; See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Under DSM-IV, a GAF score of 31 to 40 reflects some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF score of 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). See DSM- IV. A GAF score of 51 to 60 reflects moderate symptoms or moderate difficulty in social, occupational, or school functioning. The symptoms and manifestations listed under the above rating formula are not requirements for a particular evaluation, but are examples providing guidance as to the type and degree of severity of these symptoms. Consideration also must be given to factors outside the rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In this case, the Veteran's claim for increase is reviewed based on medical findings first reflected in a report of a January 2003 VA general medical examination that suggested that the Veteran's anxiety disorder had increased in severity. Since then, the Veteran was awarded an evaluation of 50 percent prior to September 10, 2007, and an evaluation of 70 percent beginning on September 10, 2007 to May 11, 2010 when a 100 percent rating was assigned. As the assignment of the 100 percent reflects the full benefit sought as of that date, the Board will only address question of a higher evaluation as it pertains to the appeal prior to May 12, 2010. Based on a review of this record, the Board finds that the signs and symptoms of the service-connected anxiety disorder reflect general worsening over the course of the period of the appeal. Prior to November 19, 2006, however, the disabling manifestations of the service-connected anxiety disorder are not shown to meet the criteria for an increased rating in higher than the already assigned 50 percent. Beginning on November 19, 2006, the Board finds, the service-connected anxiety disorder is first shown to have been productive of a disability picture that more closely resembled the criteria warranting the assignment of a 100 percent rating. Thus, the stages ratings in this case are adjusted to reflect these determinations. 38 C.F.R. § 4.71a; Hart, 21 Vet. App. 505. Prior to November 19, 2006 Based on a review of the above evidence of record, the Board finds that preponderance of the evidence is against the claim to the extent that the service-connected anxiety disorder is not shown to warrant an evaluation in excess of 50 percent prior to November 19, 2006. The January 2003 VA examination report showed that the Veteran complained that the medication he took for the service-connected anxiety disorder prevented him from driving and gaining employment. A clinical examination revealed no abnormalities. A diagnosis of anxiety disorder was confirmed. The examiner noted that the Veteran intended to resume his treatment at the VA mental health clinic in the upcoming months. The VA mental treatment records starting in June 2003 showed that the Veteran reported experiencing "very few panic attacks" since relocating to Arizona. He described his panic attacks as being manifested by symptoms of increased anxiety, rapid heartbeat and sweaty hands. He denied having any problems with crowds. On mental status examination, the examining VA psychiatrist observed that the Veteran was appropriately dressed and groomed, but appeared to be "somewhat cautious and wary." His speech was guarded, and his attention was distracted at times. The Veteran's affect was restricted, and his mood was anxious. The Veteran's insight was evaluated as fair, and his judgment was considered good. An August 2003 VA mental health treatment record reflected that a mental status examination showed that the Veteran was oriented, pleasant and cooperative. He had no abnormal movements, and his speech was normal. His affect and mood were appropriate. There was no evidence of impaired thought content, memory or cognitive function. The Veteran was assigned a GAF scaled score of 55. Subsequent VA mental health treatment records continued to reflect an assigned GAF score of 55. In May 2004, the Veteran was afforded a VA psychiatric examination to evaluate the severity of the service-connected anxiety disorder that showed that he had complained of a feeling of restlessness, difficulty sleeping, impaired concentration, irritability, muscle tension, stress, feeling overwhelmed with pressure, and feeling like he was unable to work because of his problems with concentration and pressure. The Veteran reported that he regularly attended his church and engaged in social activities through this organization. A mental status examination noted that the Veteran's memory was intact and that he was oriented and cooperative. He had normal speech, thought processes and thought content. He denied having any suicidal ideations or homicidal ideations. There was no evidence of delusions or hallucinations. His concentration was considered intact. His mood was anxious, and his affect was restricted. The Veteran's judgment was evaluated as good, but his insight was considered to be fair. The Veteran was assigned a GAF score of 55. The subsequent VA and private mental health treatment record reflected similar findings to the extent that the Veteran was assessed with GAF scores ranging from 50 to 60. The Veteran underwent another VA psychiatric examination in May 2005 and complained of excessive worry, feeling of restlessness, fatigue, and irritability. He was concerned about his concentration and focus. The Veteran reported being recently employed for five months before he was laid off and feeling that his symptoms affected his ability to find a new job. He reported being very involved in his church and socializing with people both at church and outside church. On mental status examination, the Veteran was noted to be oriented and cooperative; his memory was intact; his speech, thought processes, and thought content were normal; his mood was anxious, and his affect was restricted. The Veteran was assigned a GAF score of 55. In December 2005, the Veteran underwent a neuropsychiatric evaluation at the VA medical center in conjunction with his complaints of cognitive and memory impairment. Based on the clinical evaluation, the examining specialist felt that it was possible that the Veteran's psychiatric symptoms affected his concentration and memory. The record also contains documents that the Veteran submitted in conjunction with his application for disability benefits from the Social Security Administration. These records include an October 2005 and April 2006 private evaluation reports as well as a February 2006 handwritten statement from the Veteran's treating VA physician. The October 2005 private report noted that a mental status examination showed that the Veteran was appropriately dressed and groomed, was oriented and made good eye contact with the examiner. His speech was normal, but his thought processes and thought content were circumstantial. The Veteran's insight, judgment, memory and concentration were evaluated as fair. His mood was anxious, but his affect was appropriate. He was assigned a GAF scaled score of 60. In a February 2006 medical statement, the Veteran's treating physician stated that he was unable to work because of his anxiety disorder. An April 2006 private evaluation report noted findings similar to those recorded in the October 2005 private report. It was noted that the Veteran complained that his anxiety, impaired concentration, memory problems, and stress impacted his ability to get a job. Based on this clinical assessment, the examiner found that the Veteran could "work independently and concentrate satisfactorily on tasks" and would be able to work in a noncompetitive environment. The examiner added that the clinical findings suggested that the Veteran was malingering. A May 2006 Social Security Administration evaluation report showed that, based on a review of the documents, the Veteran displayed "less than optimal effort" and that his true abilities were above what he achieved on test scores. The Social Security Administration examiner also found that the Veteran's social skills were intact and concluded that he could carry out both simple and detailed instructions. The Social Security Administration examiner concluded that the Veteran could work in a low stress work environment and could complete a normal work day. The VA treatment records dated in 2006 continued to show that the Veteran complained of having increased anxiety, an anxious mood, irritability, low energy, stress, and impaired concentration and focus. Collectively, the aforementioned medical evidence reflects that, for this initial stage of the appeal, the service-connected disability picture was manifested predominantly by symptoms of anxiety, constricted affect, anxious mood, irritability, feeling restless, feeling overwhelmed and stressed, low motivation, fatigue, impaired concentration and focus, sleeping impairment, and circumstantial thought processes and content. To the extent that the Veteran asserts that his symptomatology affected his ability to obtain and maintain work during this period, he is consistently shown to have maintained effective relationship with his church and related activities. While his initial 2003 VA treatment showed that the Veteran had guarded speech, none of the subsequent clinical evaluations revealed any significant abnormalities. Accordingly, on this record, these disabling manifestations do not meet the criteria for an evaluation in excess of a 50 percent disability. 38 C.F.R. § 4.130 including Diagnostic Code 9400. Specifically, the evidence does not show that the Veteran has obsessive 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, spatial disorientation, or neglect of personal appearance and hygiene. The Veteran reported experiencing some panic attacks, but at no point during the period were the panic symptoms described as near-continuous. With respect to the occupational impairment, the Veteran is noted to have reported that his anxiety affected his ability to work. However, the record also demonstrated that in conjunction with his Social Security Administration benefit application, the Veteran underwent functional assessment that showed that he was able to work independently, despite his anxiety symptoms. The findings also included a determination that he had the ability to carry out both simple and detailed instructions and was able to maintain a normal workload in a competitive work environment. While the anxiety symptoms appear to impair his occupational functioning, the inability to establish and maintain effective work relationships is clearly not shown at this time. The Board has considered the February 2006 medical statement from the Veteran's treating VA physician. However, no additional was support was provided for the medical conclusion that the Veteran was unable to work because of his anxiety disorder or that it was based on a full review of the evidence as reflected in the other evaluations from this period. In addition, the Board has considered the GAF scores assigned by the various medical professionals over the time prior to November 19, 2006. These GAF scores generally ranged between 55 and 60 and reflected no more than moderate symptoms overall. These scores do not indicate findings that would warrant a higher rating for the period in question. In light of the foregoing, the Board concludes that the evidence of record does not show that his overall level of severity of the service-connected anxiety disorder meets the criteria for a higher rating under 38 C.F.R. § 4.130 prior to November 19, 2006. Beginning on November 19, 2006 Beginning on November 19, 2006, the date of a VA examination, the Board finds that the service-connected anxiety disorder is shown to have begun a process of chronic worsening to where it more nearly resembled the criteria for the assignment of a 100 percent, evaluation. The report of the VA psychiatric examination report showed that the Veteran was initially assigned a significantly lower GAF score of 32, indicative of some impairment in reality testing or communication, or major impairment. The Veteran complained of feeling "mental anguish," low energy, decreased appetite, panic attacks, and inability to make decisions. A Mental status examination noted findings of obsessive-compulsive symptoms, paranoid thoughts, and impaired judgment and insight. The VA examiner also observed that the Veteran had a constricted affect and irritable mood. His memory and concentration were intact, but he demonstrated low self-esteem. While the VA examiner noted that, in addition to mild anxiety, the Veteran had personality traits that primarily affected his ability to function, the examiner did not really differentiate between the conditions. The Board will consider all of the symptomatology contained in the evidence. See Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of a service-connected disability and a nonservice-connected disability, reasonable doubt must be resolved in the appellant's favor and the symptoms in question attributed to the service-connected disability). Subsequent VA medical records continue to show that the Veteran was assigned a GAF scores ranging between 32 and 40. A September 10, 2007 VA mental health treatment record showed that his treating VA psychiatrist felt that the Veteran was unemployable because of the severity of his anxiety disorder. At that time, the Veteran complained of decreased mood, increased anxiety, increased irritability, decreased memory and concentration, and decreased motivation. On mental status examination, the examining psychiatrist observed that the Veteran had a depressed mood and blunted affect. Later VA treatment records reflect similar findings. In July 2013, two VA medical opinion reports were obtained. In both reports, the VA examiners noted a review of the claims folder and highlighted pertinent mental health findings in the medical documents. The first VA examiner in the July 15, 2013 report opined that the evidence in the medical records prior to September 10, 2007 demonstrated that the anxiety disorder was mild to moderate in severity and that, since September 10, 2007, his anxiety disorder was manifested by severe symptoms. In contrast, the second VA examiner in the July 25, 2013 report concluded that the evidence in the medical records showed that the Veteran's symptoms had been consistently poor both prior to and since September 19, 2007 and resulted in total occupational and social impairment. In support of this medical conclusion, the second VA examiner specifically noted that the November 2006 VA examination report assigned a GAF score of 32 and subsequent VA medical records continued to assign scores ranging from 32 to 40. Accordingly, based this medical evidence, the Board finds that the service-connected disability picture is shown to have clearly worsened beginning with the November 19, 2006, VA psychiatric examination report. Although in the July 25, 2013 report the VA examiner opined that the severity of the Veteran's disability was consistently severe both prior to and since September 10, 2007, that VA examiner clearly based his statement on the findings first recorded in the November 2006 VA examination report and not any earlier. Moreover, in the July 15, 2013 report, the other VA examiner opined that the earlier medical evidence demonstrated that the Veteran's symptoms were at most moderate in severity. This would be consistent with the currently assigned 50 percent rating for that portion of the appeal. Hence, on this record, the Board finds that, beginning on November 19, 2006, the service-connected disability picture was productive of a level of impairment that closely approached total occupational and social inadaptability as reflected in the one medical opinion. The Board notes here that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. In resolving all reasonable doubt in the Veteran's favor, the Board finds that already assigned 100 percent rating must be made effective beginning on November 19, 2006, but not earlier in order to be consistent with evidence of record. Extraschedular Consideration prior to November 19, 2006 For the entire period prior to November 19, 2006, the Board has considered whether an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made 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"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the disability at issue that would render the schedular criteria inadequate for rating the service-connected anxiety disorder. The Veteran's main symptoms are contemplated in the assigned rating of 50 percent prior to November 19, 2006. A rating in excess of that assigned is provided for certain manifestations of his anxiety disorder but the probative evidence reflects that those manifestations are not present in this case. The rating criteria adequately describe the severity and symptomatology of the service-connected mental health disability. Therefore, the Veteran's disabilities are contemplated by the rating schedule and no extraschedular referral is required. Lastly, the Board notes that the Veteran has been assigned a total compensation rating based on individual unemployability (TDIU) since January 23, 2003, the date of his original claim for increased rating for anxiety disorder. Therefore, as applied to the ratings in effect at the time this appeal was received by the Board, for the period prior to November 19, 2006, a rating in excess of 50 percent for anxiety disorder is denied; and as of November 19, 2006, forward, a rating of 100 percent for anxiety disorder is granted. The Board notes that, in reaching these conclusions, the benefit of the doubt doctrine has been applied to resolve the matters on appeal in a manner favorable to the Veteran. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An increased evaluation in excess of 50 percent prior to November 19, 2006 for the service-connected anxiety disability is denied. An increased rating of 100 percent, beginning on November 19, 2006 for the service-connected anxiety disorder is granted, subject to the regulations controlling disbursement of VA monetary benefits. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs