Citation Nr: 1338427 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 10-24 381 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an initial rating for an anxiety disorder in excess of 30 percent prior to March 2, 2010. 2. Entitlement to a rating for an anxiety disorder in excess of 50 percent after March 2, 2010. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Jan Dils, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran served on active duty from February 1971 to August 1973. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which granted service connection for an anxiety disorder and assigned an initial evaluation of 30 percent, effective from November 9, 2009. The Veteran appeared before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing held in August 2012. The hearing transcript is of record. In an April 2012 rating decision, the RO increased the disability evaluation to 50 percent, effective from March 2, 2010. As a higher rating is available before and after March 2, 2010, and because the Veteran is presumed to seek the maximum available benefit, the claim for a higher rating remains on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. Prior to March 2, 2010, the Veteran's anxiety disorder was manifested by occupational and social impairment with reduced reliability and productivity. 2. From March 2, 2010, the Veteran's anxiety disorder was manifested by occupational and social impairment with deficiencies in most of the areas of work, school, family relations, thinking and mood. 3. Resolving all doubt in the Veteran's favor, the criteria for TDIU are met. CONCLUSIONS OF LAW 1. Prior to March 2, 2010, the criteria for an initial disability rating of 50 percent, but no higher, for anxiety disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9400 (2013). 2. From March 2, 2010, the criteria for a disability rating of 70 percent, but no higher, for anxiety disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, DC 9400 (2013). 3. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and assist the Veteran in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). In this decision, the claim for a higher initial rating for an anxiety disorder arises from disagreement with the initial disability rating assigned following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). See also, VA VCAA letter dated in November 2009. The Board also grants TDIU. As this represents a complete grant of the benefit sought on appeal, no discussion of VA's duty to notify and assist with respect to entitlement to TDIU is necessary. Additionally, VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claim. See 38 U.S.C.A. § 5103A (West 2002 & Supp. 2013) and 38 C.F.R. § 3.159(c) (2013). All available evidence pertaining to the Veteran's claim has been obtained. Service treatment records and post-service medical records have been associated with the claims file. Records from the Social Security Administration (SSA) are also of record. The Veteran has not indicated there are any additional records that VA should seek to obtain on his behalf. The Veteran also was provided with VA examinations in conjunction with his claim. The Board finds that the VA examination reports are adequate for the purposes of deciding the claim on appeal because the examiners conducted clinical evaluations, reviewed the medical history, and described the disability in sufficient detail so that the Board's evaluation is an informed determination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Finally, the Veteran was afforded a hearing before the undersigned VLJ in August 2012, during which he presented oral argument in support of his claim. The Board is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the hearing, the VLJ did not note the bases of the prior determinations. The VLJ asked specific questions, however, directed at identifying whether the Veteran had symptoms meeting the schedular criteria for a higher rating. The VLJ also sought to identify pertinent evidence not currently associated with the record, and the Veteran volunteered his recent treatment history and symptoms. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. I. Increased Ratings 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). The 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). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Also, staged ratings are 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). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Veteran's service-connected anxiety disorder is rated under 38 C.F.R. § 4.130, DC 9400. Under DC 9400, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned 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; 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 worklike setting); inability to establish and maintain effective relationships. 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. In assessing the evidence of record, it is important to note that the 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). Historically, SSA records reveal that the Veteran suffered a back injury on the job in 1990 and was unable to return to work as a truck driver/truck mechanic. He was awarded disability benefits by way of a June 1993 SSA administrative decision. The primary diagnosis was disorder of the back, discogenic and degenerative; and the secondary diagnosis was somatoform disorders. The SSA records also reflect that the Veteran had suffered from psychiatric symptoms since he underwent an intravenous pyelogram procedure in 1984 and had an adverse reaction. In June of 1997, an SSA consultant determined that due to the chronic and severe nature of his mental impairments (generalized anxiety disorder with panic attacks) the Veteran was unable to handle the stress and pressure of a normal workday/workweek. At a VA examination in December 2009, the Veteran reported that he had been married since 1973 and his marriage was "okay." He indicated that he had a very good relationship with his son. He also reported that he had a lot of friends, and helped out with veteran organizations, participated in military funerals, transported those who are unable to get out, and went fishing with some of them. He also stated that he socialized with his friends three or four times a week. However, the Veteran also reported that he when he gets depressed he tended to isolate himself socially. He did not like crowds. He denied history of suicide attempts, ideation, intent or plan, as well as any violent or assaultive behavior. He reported his current functioning was limited and he did not feel like doing anything. He reported panic attacks that occurred daily, but were generally mild. The Veteran reported that his current symptoms were well-controlled by his medication and his therapy helped a lot. He also indicated that he retired in 2003 due to a back injury. On mental status examination, the Veteran was dressed appropriately. His psychomotor activity and speech were normal. His attitude was cooperative and friendly. Affect was normal and mood was good. Attention was intact and he was fully oriented. Thought process and content were unremarkable and no delusions were present. Judgment and insight were not impaired. No hallucinations or inappropriate behavior were present. There were no homicidal or suicidal thoughts and impulse control was good. Recent memory was moderately impaired, but remote and immediate memory was normal. Following the clinical examination, the examiner diagnosed anxiety disorder, not otherwise specified. The GAF score was 60 to 65. The examiner indicated that the anxiety disorder resulted in an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to mental disorder signs and symptoms, but generally had satisfactory functioning. The examiner stated further that depression, anxiety, panic attacks, social withdrawal and low energy appeared to cause some impairment in social tasks, but the Veteran reported that the medication was helpful and he could generally function well. VA treatment records from 2009 to the present show the Veteran denied suicidal ideation or intention. A March 2010 progress note shows the Veteran reported an increase in his panic attacks. On mental status examination he was noted to be cooperative and dressed appropriately. His speech and eye contact were normal. The diagnosis was depression and he was given a GAF score of 55. He also reported the following symptoms occurred on a daily basis: little interest in activities, depression, sleep impairment, feeling of failure, and impaired concentration. He denied auditory and visual hallucinations, and paranoid delusions. In December 2010, the Veteran submitted evidence from Dr. Atkinson, a private psychologist. Dr. Atkinson's report of a mental status examination shows the Veteran reported his marriage was 'good up to the last 15 years.' He reported that he felt depressed on a daily basis exhibited by a desire to socially isolate himself and the lack of energy. On examination, the Veteran's attention span was short. Psychomotor activity was slowed. Speech patterns were coherent. Abstract thinking was moderately impaired. Affect was somewhat diminished. His typically mood was reported as depressed or fair. He also reported mood swings. He denied suicidal ideation. He denied hallucinations. Memory was somewhat vague and non-exact. The Veteran was given a GAF score of 45. In February 2011, the Veteran submitted evidence from Dr. Moffet, a private psychiatrist. The evidence was a report entitled "Mental Assessment of Ability to do Work-Related Activities." This assessment showed that the Veteran's ability to use judgment, function independently, understand, remember and carry out simple job instructions was only slightly limited due to his depression and anxiety. The Veteran's depression and anxiety had a moderate affect on his ability to follow work rules and relate to coworkers. His ability to deal with the public, interact with supervisors, and maintain attention and concentration was markedly limited. His ability to understand, remember and carry out complex job instructions was marked; the ability to understand, remember and carry out non-complex job instructions was moderately limited. His ability to complete a normal work week without interruptions from psychologically-based symptoms and to perform at a consistence pace was markedly limited. His ability to deal with work stressors was extremely limited. In a February 2011 report, a licensed social worker, S.P., indicated that the Veteran's anxiety and depression symptoms had caused marked impairment in social, occupational, and interpersonal functioning. The social worker provided a GAF score range of 41 to 50. At a VA examination in March 2011, the Veteran reported that his symptoms had worsened and included anger, anxiety attacks, panic attacks, decreased appetite and libido, difficulty concentrating, irritability, marital discord, memory difficulties, depression, social withdrawal, impaired sleep, and decreased motivation. The severity of these symptoms ranged from moderate to severe. The Veteran described his relationship with his wife as "she goes her way I go mine." His relationship with his son was reportedly 'excellent.' On mental status examination, the Veteran was dressed appropriately and had good hygiene. His speech and eye contact were normal. Thought processes showed no unusual ideation, signs or symptoms of a thought disorder. He denied visual and auditory hallucinations, and denied suicidal and homicidal ideations. There were no delusions, obsessive or ritualistic behavior, panic attacks that interfered with routine activities, assaultive behavior, or impaired impulse control. The Veteran's depression and anxiety, decreased motivation, and sleep difficulties did interfere with routine activities. Judgment and insight were not impaired. Affect was appropriate to content. His mood was described as 'generally calm with medication.' The examiner provided an AXIS I diagnosis of anxiety disorder, NOS. The examiner determined that the Veteran has mild to moderate impairment from an occupational viewpoint and moderate social impairment. The Veteran's GAF score range was 60 to 51, and the actual score was 60, reflective of moderate symptoms/moderate difficulty in social, occupational, or school functioning. The examiner further determined that there was no total occupational and social impairment due to the mental disorder's signs and symptoms, but there was an occasional decrease in work efficiency and intermitted periods of inability to perform occupation tasks due to mental disorder signs and symptoms, but the Veteran generally had satisfactory functioning. In May 2012, a private vocational rehabilitation specialist submitted a Vocational Evaluation Report. This report shows the Veteran had difficulty getting along with his family and neighbors and therefore had limited contact with both. In May 2012, the Veteran submitted a "Mental Assessment of Ability to do Work-Related Activities" completed by Dr. Atkinson. This assessment showed that the Veteran's ability to use judgment, function independently, understand, remember and carry out simple job instructions was only slightly limited due to his depression and anxiety. His ability to follow work rules and maintain attention and concentration was moderately limited. His ability to understand, remember and carry out non-complex job instructions was moderately limited; the ability to understand, remember and carry out complex job instructions was markedly limited. His ability to complete a normal work week without interruptions from psychologically-based symptoms and to perform at a consistence pace was markedly limited. His ability to relate to coworkers, interact with supervisors, and deal with work stressors was markedly limited. His ability to deal with the public was extremely limited. In an August 2012 letter, S.P. indicated that the Veteran had become increasingly avoidant and would not relate predictability in any social situation. S.P. also determined that the Veteran would have occupational difficulties, including an inability to deal with work stressors. At the hearing before the undersigned, the Veteran testified that he is very isolated socially and no longer has any friends. He also was unable to go fishing anymore. However, he testified that he sees his siblings about every six months and talks to them on the phone sometimes. He stated that he maintained a good relationship with his son, but had recently separated from his wife. A. Rating Period Prior to March 2, 2010 For the period prior to March 2, 2010, the Veteran's anxiety disorder manifested with symptoms that more closely approximate the criteria for a 50 percent rating. The clinical findings noted in the VA treatment records and the December 2009 VA examination report, and the Veteran's competent and credible lay statements, show the anxiety disorder primarily manifested with symptoms of anxiety, depression, panic attacks, disturbances of motivation and mood, impaired sleep and social isolation. The evidence further shows that all of these symptoms have resulted in no more than a moderate degree of social and occupational impairment. The Veteran's symptoms are accounted for in the assignment of a disability rating of 50 percent for this period. The Board has considered whether a rating higher than 50 percent is warranted for this appeal period, but finds that the Veteran's symptoms do not more closely approximate the criteria for a 70 percent evaluation. That is, the cumulative findings do not reflect occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood which would indicate disability of even greater severity. No deficits with respect to judgment or thinking are shown by the evidence. There is no evidence in the record to suggest that he had any suicidal ideation, near-continuous panic or depression affecting the ability to function, impaired impulse control, disorientation, neglect of hygiene, or an inability to establish and maintain effective relationships during this period. The Veteran does not contend otherwise. At the VA examination in December 2009 the Veteran reported that he had a lot of friends, and helped out with veteran organizations, participated in military funerals, transported those who are unable to get out, and goes fishing with some of them. The examination report also shows that while the Veteran only had an 'okay' relationship with his wife; he maintained a good relationship with his son. It is also significant that the VA examiner determined the Veteran's overall social and occupational functioning was only moderately effected by his anxiety disorder. This was based upon a clinical interview and examination, and is therefore considered highly probative. Finally, the GAF scores noted in the record were between 55 and 60, which is indicative of no more than moderate impairment. Based on the totality of the evidence, the Board finds that a 50 percent evaluation, but no higher, is warranted for the entire period prior to March 2, 2010. At no point in time does the evidence show that the criteria for a higher rating than 50 percent were more nearly approximated. See Fenderson v. West 12 Vet. App. 119, 126 (1999); 38 U.S.C.A. § 5107(b). B. Rating Period after March 2, 2010 Resolving all doubt in favor of the Veteran, the Board finds that for the period after March 2, 2010, his anxiety disorder manifested with symptoms that more closely approximate the criteria for a 70 percent rating. The private and VA clinical findings differ greatly as to the severity of the Veteran's anxiety disorder during this period. The private findings suggest that the Veteran has serious difficulty in establishing and maintaining effective social and work relationships due to his anxiety symptoms. In his February 2011 report Dr. Atkinson provided a GAF score of 45. In another February 2011 report S.P., a social worker, indicated the Veteran's symptoms caused marked social and occupational impairment. He provided a GAF range of 41 to 50. In an August 2012 letter, S.P. opined that the Veteran is unable to deal with work stressors. In their respective "Mental Assessment of Ability to do Work-Related Activities," Drs. Moffett and Atkinson both indicated that the Veteran's ability to complete a normal work week without interruptions from psychologically-based symptoms was markedly limited. Finally, the May 2012 vocational rehabilitation report essentially indicates that the Veteran has total occupational impairment due to his anxiety disorder. On the other hand, the March 2011 VA examination report reflects no more than moderate social and occupational impairment. The VA examiner opined that the Veteran's social and occupational functioning is only moderately effected by his anxiety disorder, and his symptoms are not severe enough to cause total social and occupational functioning. The examiner assigned a GAF score of 60. After careful consideration of the evidence, the Board is resolving reasonable doubt in favor of the Veteran. 38 C.F.R. § 4.3. In reaching this decision, the Board notes that the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). The criteria for a 70 percent rating for the service-connected adjustment disorder are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. See Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). As clearly reflected by the Veteran's competent and credible report regarding his symptoms and the VA and private clinical findings; deficiencies in the area of work, family relations, thinking, and mood have been demonstrated. The Veteran has competently and credibly reported that his symptoms include anger, anxiety attacks, panic attacks several times a week, difficulty concentrating, irritability, marital discord, memory difficulties, depression, social withdrawal, impaired sleep and decreased motivation. He describes the severity of these symptoms as ranging from moderate to severe. In addition, both the VA examiner and the private clinicians have opined that the Veteran's has occupational and social impairment as a result of his symptoms. Work impairment is evidenced as both the February 2011 and May 2012 reports from Drs. Moffet and Atkinson indicated that the Veteran's ability to complete a normal work week is markedly limited. In addition, the vocational rehabilitation specialist determined in May 2012 that the Veteran's non-exertional limitations that are solely associated with military service would prevent him from engaging in any type of gainful employment. Family relations are impaired as the Veteran has been distant from his family members, especially his wife, from whom he reportedly separated in August 2012. Dr. Atkinson indicated in his December 2010 report that the Veteran's abstract thinking was moderately impaired. The March 2011 VA examiner noted that there were "moderate inefficiencies" in the Veteran's immediate and delayed verbal memory. The Veteran has testified that he has impaired concentration, and the private clinicians' findings lend support to his testimony. Thus, deficiencies in thinking are demonstrated. The Veteran's mood has also been impaired, as reflected by chronic problems with anxiety, a sense of impending doom, depression, lack of energy, and social withdrawal. The Board notes that in his August 2012 report, S.P. remarked that the Veteran has become increasingly avoidant and is a 'recluse.' Finally, the Board is mindful of the Veteran's GAF scores of 45 reported by Dr. Atkinson in December 2010, and his GAF score range of 41 to 50, as reported by S.P. in February 2011. A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). The Board has considered whether a rating higher than 70 percent is warranted for this appeal period, but finds that the Veteran's symptoms do not more closely approximate the criteria for a 100 percent evaluation. The cumulative evidence does not suggest to the Board that the Veteran is incapable of either establishing or maintaining effective social and work relationships, or that he is totally impaired due to the anxiety disorder. While the Veteran is very isolated socially, no longer has any friends, and has been described as a 'recluse,' he testified that he still maintains some contact with his family, talks to his siblings, and has a good relationship with his son. He also maintains a good relationship with S.P., whom he considered a friend. Thus, total social impairment is not shown. In addition, there are no objective findings (or subjective report of) any gross impairment in thought processes or communication, inappropriate behavior, danger of hurting self or others, inability to perform activities of daily living, disorientation to time or place, or significant memory loss. The Veteran has also consistently denied having any delusions, hallucinations, and suicidal or homicidal ideations. A 100 percent rating is not warranted based on these findings. Based on the totality of the evidence, the Board finds that a 70 percent evaluation, but no higher, is warranted for the entire period after March 2, 2010. At no point in time does the evidence show that the criteria for a higher rating than 70 percent are more nearly approximated. See Fenderson v. West 12 Vet. App. 119, 126 (1999); 38 U.S.C.A. § 5107(b). C. Extraschedular Evaluation In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that neither the first nor second Thun element is satisfied here. Throughout the appeal, the Veteran's service-connected anxiety disorder has primarily manifested with symptoms of anxiety, depression, social detachment, and frequent panic attacks. These manifestations are contemplated in the applicable rating criteria. See 38 C.F.R. § 4.130, Diagnostic Codes 9201- 9940 (providing ratings on the basis of occupational and social impairment due to mental disorders). For all mental disorders set forth in these diagnostic codes, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant a particular evaluation; they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). In other words, the schedular criteria for mental disorders contemplate a wide variety of psychiatric manifestations. Given the variety of ways in which the rating schedule contemplates occupational and social impairment for mental disorders, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is primarily, but not exclusively, manifested by occupational and social impairment due to such symptoms as anxiety, depression, social detachment, and frequent panic attacks. In short, there is nothing exceptional or unusual about the Veteran's anxiety disorder because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet.App. at 115. Even if the Board were to find that step one of Thun had been satisfied, extraschedular referral would still not be warranted because the Board also finds that Thun step two is not satisfied. See Johnson v. Shinseki, 26 Vet.App. 237, 247 (2013) (en banc) (error in Thun step one analysis is harmless were Board makes an adequate finding that Thun step two is not satisfied). With respect to the second Thun element, there is no evidence of frequent hospitalization. Although the anxiety disorder is shown to cause some interference with employment, the schedular criteria specifically allow for occupational impairment (even total occupational impairment) and therefore do not warrant the conclusion that the Veteran's disability picture is exceptional or unusual. Total occupational impairment as a result of gross impairment of thought, suicidal ideation, homicidal ideation, and an inability to perform activities of daily living is not present in this case. The cumulative record is void of any findings of interference with employment beyond that which is contemplated by the applicable schedular criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of an extraschedular rating is not warranted. II. TDIU The Veteran asserts that he is unemployable due to his service-connected disabilities. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2013). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (2013). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15 (2013). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of non-service connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). All Veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b). In cases where the scheduler criteria are not met, an extraschedular rating is for consideration. 38 C.F.R. § 3.321. The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The sole fact that the Veteran is unemployed or has difficulty obtaining employment is not enough. The assignment of a rating evaluation is itself recognition of industrial impairment. Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Factors to be considered are the Veteran's education, employment history, and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). As a result of the Board's determinations, the Veteran is service-connected for gastroesophageal reflux disease (GERD) with peptic ulcer disease, rated 30 percent disabling and for anxiety disorder, rated 50 percent disabling prior to March 2, 2010, and rating 70 percent thereafter. The Veteran has a total combined rating of 70 percent prior to March 2, 2010, and a total combined rating of 80 percent thereafter. Therefore, the criteria set forth in 38 C.F.R. § 4.16(a) is satisfied. The question remaining then is whether the Veteran is precluded from obtaining or engaging in substantially gainful employment due to his service-connected disabilities. Historically, SSA records reveal that the Veteran suffered a back injury on the job in 1990 and was unable to return to work as a truck driver/truck mechanic. The SSA records also reflect that in June of 1997, an SSA consultant determined that due to the chronic and severe nature of his mental impairments (generalized anxiety disorder with panic attacks) the Veteran was unable to handle the stress and pressure of a normal workday/workweek. SSA records show the Veteran received a GED after having quit school in the 11th grade. His prior work history included work as a mechanic and a truck driver. In a report dated in February 2011 S.P., a social worker, indicated the Veteran's psychiatric symptoms caused marked social and occupational impairment. He provided a GAF range of 41 to 50. At a March 2011 VA examination, a VA examiner determined that there was only mild to moderate impairment due to the service-connected anxiety disorder from an occupational standpoint. The examiner did not specifically opine as to whether the Veteran was precluded from obtaining or engaging in substantially gainful employment. In October 2011, a VA examiner offered an opinion that the Veteran's service-connected GERD with peptic ulcer disease would cause no limitations with regard to his ability to work. Several private providers have submitted evidence to support a finding that the Veteran is unable to work due solely to his service-connected anxiety disorder. In an August 2012 letter, S.P. essentially opined that the Veteran is unable to deal with work stressors due to his psychiatric difficulties. In their respective "Mental Assessment of Ability to do Work-Related Activities," Drs. Moffett and Atkinson both indicated that the Veteran's ability to complete a normal work week without interruptions from psychologically-based symptoms was markedly limited. Of particular significance is a vocational evaluation report completed in May 2012 by a vocational rehabilitation specialist. The specialist's report indicates that the Veteran discontinued his education in the 11th grade and later obtained a GED. The Veteran's past employment history consisted of having worked as a diesel mechanic for 14 years and on a strip mine for one year as a laborer. The Veteran's self-described computer skills were 'very basic.' The specialist determined that the Veteran's past employment is skilled, but those skills would not transfer to light or sedentary employment; the Veteran has no clerical or office skills. The specialist also determined that the Veteran is not employable in a competitive labor market, and his non-exertional limitations that are solely associated with military service would prevent him from engaging in any type of gainful employment. The specialist made clear that the 'non-exertional limitations' are clearly and solely associated with his service-connected psychiatric condition. To the extent that SSA benefits were awarded due, in part, to a back condition, the impact of the Veteran's back condition on his employability has not been considered. Nonservice-connected disabilities may not be considered in the TDIU determination. See 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). However, the Board finds it significant that SSA determined that the Veteran was disabled based on a secondary diagnosis of affective and somatoform disorders many years ago. The private and VA clinical findings differ greatly as to the severity of the Veteran's occupational impairment caused by his anxiety disorder. The private findings suggest that the Veteran is unable to obtain and maintain gainful employment due to his anxiety symptoms. The VA findings suggest that no more than moderate occupational impairment is present. 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 a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has no reason to doubt or question the veracity of the positive evidence of record. Accordingly, based on the totality of the evidence in this case, the Board will resolve reasonable doubt in the Veteran's favor and find that his service-connected anxiety disorder warrants a grant of TDIU. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 4.16 (2013). ORDER Subject to the laws and regulations governing payment of monetary benefits, a 50 percent rating, but not higher, for an anxiety disorder is granted prior to March 2, 2010. Subject to the laws and regulations governing payment of monetary benefits, a 70 percent rating, but not higher, for an anxiety disorder is granted from March 2, 2010. Subject to the laws and regulations governing payment of monetary benefits, TDIU is granted. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs