Citation Nr: 1338831 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 09-43 000 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for an acquired psychiatric disability, to include adjustment disorder with mixed emotions, prior to June 19, 2013, and in excess of 50 percent on and after June 19, 2013. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. E. de Jong, Associate Counsel INTRODUCTION The Veteran (appellant) served on active duty from May 2003 to May 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the RO in St. Petersburg, Florida, which granted service connection for the Veteran's acquired psychiatric disability and assigned a 30 percent disability rating effective February 27, 2008. During the course of the appeal, a September 2013 rating decision increased the Veteran's initial rating for his psychiatric disability to 50 percent effective June 19, 2013. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" and VBMS systems to insure a total review of the evidence. This claim was first before the Board in April 2010. At that time the Board remanded the claim in order to provide the Veteran with a requested hearing before a Veterans Law Judge. A hearing was held at the RO in July 2010. A transcript of that proceeding is of record and has been associated with the claims file. This claim was again before the Board in November 2012. At that time the Board remanded the claim to the RO via the Appeals Management Center (AMC) in Washington, DC for further development. The development directed in the November 2012 remand has been completed, and because the Board's order was fully complied with, there is no prejudice for the Board to proceed. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. On and after August 4, 2009, the Veteran's service-connected psychiatric disability has been manifested by a consistently depressed mood, flattened affect, anxiety, chronic sleep impairment, persistent irritability, angry outbursts, and social isolation, which have resulted in occupational and social impairment with reduced reliability and productivity, but not total impairment or deficiencies in most areas. 2. Prior to August 4, 2009, the Veteran's service-connected psychiatric disability was manifested by episodes of sadness, nightmares, low energy, a low frustration tolerance, and impaired concentration, which resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but not total impairment, deficiencies in most areas, or reduced reliability and productivity. 3. The schedular criteria are adequate to rate the Veteran's service-connected psychiatric disability. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 30 percent for an acquired psychiatric disability, to include adjustment disorder with mixed emotions, prior to August 4, 2009, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9440 (2013). 2. The criteria for an increased evaluation of 50 percent for an acquired psychiatric disability, to include adjustment disorder with mixed emotions, were met as of August 4, 2009. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130 , Diagnostic Code 9440 (2013); Fenderson v. West, 12 Vet. App. 119, 126 (1999). 3. The criteria for an initial evaluation in excess of 50 percent for an acquired psychiatric disability, to include adjustment disorder with mixed emotions, have not been met at any time during the period on appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9440 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Evaluation The Veteran contends that he is entitled to an initial rating in excess of 30 percent for his service-connected psychiatric disability for the period prior to June 19, 2013. The Veteran further contends that he is entitled to an initial rating in excess of 50 percent for the period on and after June 19, 2013. The Board notes that a September 2013 rating decision increased the Veteran's initial rating for his psychiatric disability from 30 percent to 50 percent. For the reasons that follow, the Board concludes that the criteria for an increased evaluation of 50 percent were met on August 4, 2009, but no sooner. The Board further concludes that the criteria for an initial evaluation in excess of 50 percent have not been met at any time during the period on appeal. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2013). The Veteran's service-connected psychiatric disability was evaluated as 30 percent disabling for the period prior to June 19, 2013, and 50 percent disabling for the period on and after June 19, 2013, under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9440 (2013). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are 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). Under the provisions for rating psychiatric disorders, a 30 percent disability rating requires evidence of the following: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The criteria for a 50 percent rating are: 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. The criteria for a 70 percent rating are: 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; inability to establish and maintain effective relationships). The criteria for a 100 percent rating are: 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 9440. The Board notes that the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, supra. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Many GAF scores have been assigned throughout the course of the Veteran's treatment and evaluation for his psychiatric disability. It appears from the evidence of record that the Veteran's lowest GAF score was a 51, assigned in the May 2010 treatment summary letter from the Veteran's counselor W.F. at the Orlando Vet Center. This letter also notes that the Veteran's GAF scores ranged over the preceding year from 50 to 55, although the evidence of record does not appear to contain the specific dates on which those GAF scores were assigned. The Veteran's highest GAF score contained in the evidence of record appears to be a 65, assigned at the Veteran's June 2009 VA examination. According to DSM-IV, a GAF score of 41 to 50 indicates "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 Richard v. Brown, supra. A score of 51-60 represents "[m]oderate 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)." Id. Under DSM-IV, 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. Id. The Veteran's GAF scores assigned throughout the period on appeal consistently indicate mild to moderate symptoms or mild to moderate difficulty in social, occupational or school functioning. They do not tend to show deficiencies in most areas or total impairment. The Board acknowledges that the Veteran's Vet Center counselor reported the Veteran was assigned a GAF score of 50 at some point between August 2009, when the Veteran began receiving treatment at the Vet Center, and May 2010, when the counselor sent the letter to VA. The evidence of record does not appear to contain any specific information regarding the date on which this GAF score was assigned or the circumstances surrounding its assignment. While the Board acknowledges that a GAF score of 50 falls into the category reflecting serious symptoms or impairment, the Board also notes that it is at the upper end of this category. There is no evidence that indicates the Veteran was suffering from symptoms such as suicidal ideation or severe obsessional rituals during that time period, and no evidence to indicate that the Veteran's social, occupational or school functioning was markedly more impaired at a certain time during the course of his Vet Center treatment prior to May 2010 as compared to other times. The evidence of record shows the Veteran first began receiving treatment for his psychiatric disability in February 2008 at the Kissimmee Community Based Outpatient Clinic (CBOC), part of the Orlando VA Medical Center (VAMC). At his initial appointment, the Veteran reported having nightmares 1-2 times per month. He also reported episodes of sadness lasting less than one day, which he related to his living situation at the time. The Veteran denied suicidal or homicidal ideation, and the evidence of record indicates that the Veteran has consistently denied suicidal or homicidal ideation throughout the course of his treatment. The Veteran further denied auditory or visual hallucinations at his initial appointment, and the evidence of record indicates that the Veteran has never endorsed auditory or visual hallucinations at any point during his treatment. The VA psychiatrist assigned the Veteran a diagnosis of adjustment disorder with depressed mood at his initial appointment. This diagnosis was confirmed at later treatment sessions in February and April 2008, during which the Veteran continued to report nightmares, as well as sleep impairment and anxiety. The Veteran was afforded a June 2008 VA examination in connection with his psychiatric disability claim. On examination, the Veteran reported that he was receiving individual counseling and taking an antidepressant. He reported that his treatment was helping but that he still had nightmares 3-4 times per week. The Veteran reported depression, a low frustration tolerance, and frequent irritability. The Veteran further reported having a fair relationship with his parents, with whom he lived at the time, and reported having some friends but no close relationships. The Veteran did not participate in any social activities, and his hobbies consisted of computer activities and watching television. On examination, the Veteran presented with a dysphoric mood. The Veteran had intact attention, judgment, memory, orientation, and insight, as well as unremarkable speech and psychomotor activity. The Veteran reported sleep impairment, but also reported that medication was decreasing the frequency and duration of his nightmares. The Veteran did not have panic attacks or obsessive or ritualistic behavior, and had good impulse control. As noted above, the Veteran continued to deny auditory or visual hallucinations, as well as suicidal or homicidal ideation. The VA examiner assigned a diagnosis of adjustment disorder with mixed emotions and a GAF score of 55. The Veteran submitted a May 2009 statement from his mother describing his symptoms and behavior. The Veteran's mother reported that the Veteran's behavior had changed from the time he returned from Iraq, and that he had become extremely aggressive. She further reported that the Veteran had nightmares that resulted in his crying out, as well as erratic behavior. The Veteran's mother stated that he was sometimes unable to hold a civil conversation, and that he had become excessively loud and verbally abusive in conversations with her during the past several months. She also reported her belief that the Veteran was in need of major therapy. The Veteran was afforded a second VA examination in June 2009. On examination, the Veteran reported experiencing a mild depressed mood for 1-2 hours every day, as well as sleep impairment. The Veteran further reported low energy, decreased appetite, and impaired concentration. The Veteran continued to deny auditory or visual hallucinations and homicidal ideation. The Veteran did report "passive thoughts in the past," but denied any present suicidal ideation. The Veteran again had no panic attacks or obsessive or ritualistic behavior, and his judgment, insight, intelligence, thought processes, speech and psychomotor activities were intact and unremarkable. The Veteran had fair impulse control and normal memory. The VA examiner assigned a diagnosis of anxiety disorder and a GAF score of 65, which, as noted above, is the highest GAF score assigned to the Veteran in the evidence of record. The VA examiner opined that the Veteran's symptoms were not severe enough to interfere with occupational and social functioning. The Veteran began receiving treatment for his psychiatric disability at the Orlando Vet Center in August 2009. His treatment at the Vet Center was summarized in a May 2010 letter from the Veteran's counselor, W.F. The counselor noted that the Veteran participated in group and individual therapy, and that the Veteran had received diagnoses of anxiety disorder and posttraumatic stress disorder (PTSD) in addition to adjustment disorder. The Board notes that the Veteran filed a service connection claim for PTSD, but subsequently withdrew the claim. The Vet Center counselor noted that the Veteran's symptoms had been broad enough to encompass several diagnoses, but that all his symptoms were properly viewed as psychological sequelae of his one year active service in a combat zone. The counselor reported that despite treatment including medication and various types of therapy, the Veteran's symptoms remained problematic, impacting his social, vocational, and educational functioning. The counselor reported that the Veteran experienced nightmares, as well as intrusive thoughts of his war zone experiences. The counselor further reported that the Veteran had difficulty sleeping despite medication. The counselor also noted that the Veteran had a depressed mood, as well as impaired concentration and focus. The counselor reported that the Veteran had a low stress tolerance and was prone to angry outbursts, and that his outbursts had resulted in property damage and estrangement from his parents and classmates. The counselor noted the Veteran struggled with anxiety and persistent irritability, which constricted his social relationships and made them difficult to maintain. The counselor also reported that the Veteran was unemployed and struggling to stay in school. As noted above, the counselor assigned the Veteran a GAF score of 51, the lowest score of record, and stated that his GAF score had ranged in the past year from 50 to 55. At the Veteran's August 2009 Vet Center intake appointment, he reported having nightmares, getting angry often for no reason, and thinking about combat often. At his initial mental health evaluation, the Veteran presented with an anxious manner, tense motor activity, and fair judgment. The Veteran reported sleep impairment, social isolation, and depression, as well as being extremely watchful on guard. The Vet Center counselor noted that the Veteran had "considerable social and vocational impairment." Later Vet Center treatment notes from August 2009 show that the Veteran presented with a depressed mood and flat affect, and that he had difficulty with irritability and angry outbursts. These notes also show that the Veteran had enrolled at a local community college for the fall semester. Vet Center treatment notes from September 2009 indicate no changes in the Veteran's symptoms or psychosocial stressors during that time. An October 9, 2009 treatment note indicates that both the Veteran's symptoms and psychosocial stressors had increased in severity. An October 29, 2009 treatment note shows the Veteran reported still having trouble controlling his temper, and that he got into an argument with his father over using his car which led to his father calling the police. This note also shows that the Veteran reported still doing "ok" in school and that he had purchased his own car. Treatment notes from November 2009 indicate no changes in the Veteran's symptoms or psychosocial stressors during that time. A December 8, 2009 treatment note indicates that the Veteran continued to present with a dysphoric mood and flat affect, and that he thought he would fail one class due to absences. The Veteran also reported an altercation with a convenience store clerk, but the counselor noted that the Veteran was able to handle the situation correctly and avoid a negative outcome. A January 5, 2010 treatment note shows the Veteran presented with an improved mood and noted that he was doing better. He was still in school at this time and looking for his own apartment and a part-time job. A January 8, 2010 treatment note indicates a decrease in severity of the Veteran's psychosocial stressors, but no change in symptoms. A January 25, 2010 treatment note shows the Veteran continued to present with a dysphoric mood and reported an increase in irritability and a decrease in impulse control. A March 1, 2010 treatment note reflects the Veteran's report that he punched a wall in his parents' house during an angry outburst. An April 1, 2010 treatment plan indicates that the Veteran's main symptoms were irritability and anger, and that the goals of continued treatment at the Vet Center were to improve and stabilize the Veteran's mood as well as reduce the frequency and intensity of his angry outbursts. The Board finds that the criteria for an increased evaluation of 50 percent were met as of August 4, 2009, the date the Veteran began treatment at the Orlando Vet Center. The evidence of record prior to that date does not show that the Veteran's symptoms caused occupational and social impairment beyond an occasional decrease in work efficiency or intermittent periods of inability to perform occupational or academic tasks. The August 4, 2009 Vet Center records from the Veteran's initial appointment show that as of that date, the Veteran's service-connected psychiatric disability was manifested by occupational and social impairment with reduced reliability and productivity, but not by deficiencies in most areas or total impairment. At his initial evaluation, the Vet Center counselor noted that the Veteran had "considerable social and vocational impairment." At that time, the Veteran presented with an anxious manner and tense motor activity, and reported sleep impairment, depression, getting angry often for no reason, social isolation, and being extremely watchful on guard. Records throughout the course of the Veteran's Vet Center treatment indicate that the Veteran consistently presented with a depressed mood and flattened affect and consistently reported problems with irritability and managing his anger. These records reflect altercations with his family members and members of the public, which resulted in property damage and the police being called. These incidents did not, however, involve the Veteran assaulting anyone, or being arrested or charged with any criminal conduct. The Vet Center treatment records from August 2009 through April 2010 show that the Veteran consistently struggled with depression, irritability and angry outbursts. The records also show that although the Veteran remained in school throughout this time, he did fail one class in the fall semester. In his May 2010 letter, the Veteran's counselor described in detail the Veteran's difficulty in establishing and maintaining effective work and social relationships, stating that the Veteran's relationships with his parents and his classmates had become estranged due to his behavior. The Veteran's counselor also described the Veteran's disturbances of motivation and mood, noting the Veteran's depressed mood, low frustration tolerance, persistent irritability, and angry outbursts. The counselor's description of the Veteran's overall functioning in the areas of work, school, and social life indicate that the Veteran's symptoms were causing occupational and social impairment with reduced reliability and productivity from the time the Veteran began treatment at the Vet Center in August 2009. The counselor specifically stated that the Veteran's symptoms were "problematic, impacting social, vocational and educational functioning." Furthermore, the counselor noted that the Veteran's "concentration and focus remain impaired and has [sic] caused considerable difficulty in his educational endeavors." The counselor reported that the Veteran was unemployed at that time and struggling to stay in school, indicating occupational and social impairment to a significant degree. The fact that the Veteran was "struggling" to stay in school indicates more than an occasional decrease in work efficiency or intermittent periods of inability to perform his academic tasks, and instead seems to indicate continuously reduced reliability and productivity in his academic performance. As the Veteran's Vet Center treatment records from August 2009 to April 2010 and the May 2010 letter from his counselor show the Veteran was suffering from occupational and social impairment with reduced reliability and productivity throughout the course of his treatment there, the criteria for an increased evaluation of 50 percent for the Veteran's service-connected psychiatric disability were met as of August 4, 2009, the date he began his treatment at the Orlando Vet Center. Later evidence of record shows that the criteria for a rating of 50 percent continued to be met throughout the rest of the period on appeal. The Veteran's later Vet Center treatment records, his July 2010 hearing testimony, his VA treatment records, and his VA vocational rehabilitation notes reflect that the Veteran consistently reported similar symptoms from August 2009 to the present. The Veteran's third VA examination, discussed below, continued to reflect that the Veteran was suffering from occupational and social impairment with reduced reliability and productivity. However, as discussed below, the evidence of record does not show that the Veteran suffered from occupational and social impairment with deficiencies in most areas or total impairment at any time during the period on appeal. The Veteran was afforded a hearing before the undersigned at the RO in July 2010. At the hearing, the Veteran testified that he was neither employed nor attending school. The Veteran reported having panic attacks 3-4 times per week, and having nightmares at the same frequency. He also reported having an angry outburst once per day and memory loss manifested by forgetting why he was doing something or forgetting what he was doing before his current activity. The Veteran testified that his psychiatric disability had caused him to keep in touch with his friends and siblings less often than he used to. The Veteran stated that although he was looking for employment, he was concerned about how he might behave in the workplace due to his anger problems. He reported that his symptoms began during his service in Iraq and that his aggressiveness escalated after his discharge. The Veteran also stated his concerns regarding the duration and accuracy of his June 2009 VA examination, and his belief that the examination only lasted 30 minutes and as such was not a fair assessment of his disability. The Veteran reported that following his discharge he worked as a hotel security guard, but was fired after four months for having a threatening confrontation with another employee. He reported that he had last been employed in April 2007, and that at the time of the hearing he had stopped pursuing his business marketing education in order to pursue employment. The Veteran took part in a VA vocational rehabilitation program through the Orlando VAMC beginning in June 2011. Records from his initial June 2011 program session indicate that the Veteran was seeking a position in which he could work alone because he felt he might need time to adjust to working and being around people in an employment environment. A December 2011 vocational rehabilitation record shows that the Veteran began full-time work at an Orlando arena as an events coordinator during that month. Later records show that the Veteran applied for positions with overseas government contractors, and that he was hired by a contractor for a civilian position in Afghanistan beginning in January 2013. Other records in the file related to scheduling a VA examination for the Veteran show that the Veteran remained in Afghanistan through June 2013 in order to complete his contract assignment. The Veteran's treatment records from the Orlando VAMC during the period on appeal reflect that the Veteran has consistently reported a depressed mood, sleep impairment, and anxiety. These records reflect that the Veteran has continued to take an antidepressant medication throughout the period on appeal. The Veteran's VA treatment records further reflect that the Veteran has consistently denied auditory or visual hallucinations, as well as suicidal or homicidal ideation. In an April 2010 treatment note, the Veteran did report transient and passive thoughts of not wanting to live that occurred a few months prior to the note, but denied ever having any suicidal intent or plan and denied any current suicidal ideation. The VA treatment records show that the Veteran has consistently presented as alert and oriented, with good insight and judgment, unremarkable speech and psychomotor activity, and no notable memory problems. The Veteran has consistently denied any psychosis, and has presented as appropriately dressed and well-groomed for his treatment sessions. A March 2012 treatment record shows that the Veteran requested a referral to psychotherapy for depression and gambling issues, and was referred to a VA therapist for consultation. The Veteran was afforded a third VA examination in July 2013. The VA examiner noted that the Veteran's diagnoses included major depressive disorder as well as adjustment disorder, and opined that the Veteran suffered from major depression of moderate severity with agitated, anxious components. The examiner assigned a GAF score of 58. On examination, the Veteran reported some social isolation and withdrawal. The examiner indicated that the Veteran suffered occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner also indicated that the Veteran had not had consistent employment for several years. On examination, the Veteran presented as appropriately groomed and dressed, alert and oriented. His responses to questions were linear, goal-directed and logical, and his speech and psychomotor activity were normal. The Veteran denied psychosis, including auditory or visual hallucinations, and his insight and judgment were intact. The Veteran presented with a dysthymic mood and affect. His memory was within normal limits, as evidenced by tests administered during the examination. The examiner noted the Veteran's symptoms as follows: depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective social relationships. The examiner also noted that the Veteran's adaptation and adjustment appeared quite brittle and that he could be vulnerable to decompensation if he experienced unexpected life changes or losses. The examiner reported that the Veteran revealed internalized feelings of anger, frustration and resentment and that he likely expressed his anger in an unmodulated way. Of those symptoms suggestive of a 50 percent rating, the Veteran has not had circumstantial, circumlocutory, or stereotyped speech, difficulty in understanding complex commands, impaired judgment, or impaired abstract thinking at any time during the period on appeal. The Veteran does have flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, as noted in his July 2013 VA examination. The Veteran testified to having panic attacks 3-4 times per week during his July 2010 hearing, but does not appear to have reported experiencing panic attacks at any other time during the course of his treatment and evaluation. The Veteran has also asserted memory loss on several occasions, although no notable memory loss has been found during the course of his treatment and no memory loss was detected during any of the memory tests performed during his three VA examinations. The evidence as a whole shows that the Veteran's symptoms have resulted in occupational and social impairment with reduced reliability and productivity from August 2009 to the present. The preponderance of the evidence shows that the Veteran has not had deficiencies in most areas at any time during the period on appeal. Of those symptoms suggestive of a 70 percent rating, the Veteran has not had obsessional rituals which interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting his ability to function independently, appropriately and effectively, spatial disorientation, or neglect of personal appearance or hygiene at any time during the period on appeal. The Veteran has had difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to establish and maintain effective social relationships. This was reflected in the Veteran's August 2009 Vet Center intake assessment and the Vet Center counselor's May 2010 letter, as well as in the Veteran's VA vocational rehabilitation records and his July 2013 VA examination report. The Veteran has reported and clinical evidence throughout the period on appeal reflects that he is prone to angry outbursts. This suggests that the Veteran may have impaired impulse control. The Veteran's June 2009 VA examination noted the Veteran had "fair" impulse control rather than "good," a March 2010 Vet Center treatment note shows the Veteran reported punching a hole in a wall, and the May 2010 letter from the Veteran's Vet Center counselor reported that the Veteran's angry outbursts had resulted in property damage and estrangement from his parents and classmates. The Veteran has consistently denied suicidal or homicidal ideation. At his June 2009 VA examination, the Veteran mentioned that he had experienced some "passive thoughts in the past," but denied any present suicidal ideation. At an April 2010 treatment session, the Veteran again mentioned transient and passive suicidal thoughts that had occurred several months ago, but denied any present suicidal ideation. He further denied ever having a suicidal plan or intent, and stated that he would "never do anything." Based on the record as a whole, the Board finds that the Veteran has not experienced suicidal ideation at any time during the period on appeal. The clinical evidence of record does not reflect any deficiencies in the Veteran's judgment or thinking at any time during the period on appeal, and the Veteran has not reported deficiencies in these areas. Therefore, the Board finds that the Veteran does not have deficiencies in judgment or thinking. The Board also finds that the Veteran does not have deficiencies in the area of family relations. The evidence of record reflects that during a portion of the period on appeal, the Veteran was living with his parents and had a fair relationship with them. The Veteran's mother submitted a May 2009 statement indicating that her relationship with the Veteran is close and that she is supportive of his mental health treatment. The evidence of record further reflects that the Veteran maintains relationships with his siblings, although those relationships may not be as close as they once were. The evidence of record appears to show the Veteran has been able to maintain functional relationships with his parents and siblings. Although the Board acknowledges that the Veteran's relationships with his family members may have become more difficult as a result of his psychiatric symptoms, he has reported that they are still of "fair" quality and has been able to sustain these fair quality relationships throughout the period on appeal. As such, the evidence does not show a deficiency in the area of family relations, as contemplated by the rating criteria, at any time during the period on appeal. The Board finds that the Veteran does have deficiencies in mood. The Veteran has consistently presented with a dysthymic mood throughout the course of his treatment and evaluation, and has consistently taken an antidepressant medication. Furthermore, the Veteran reports and clinical evidence of record indicates that the Veteran is frequently irritable and prone to angry outbursts, and as such the evidence reflects deficiencies in mood. Vet Center treatment notes from August 2009 through January 2010 indicate that the Veteran was attending a local community college. An April 2010 VA treatment record noted that the Veteran was pursuing an associate degree in business marketing, and that the Veteran was projected to graduate in 2011. The treatment record further noted that the Veteran had recently received a failing grade in a course and subsequently had to drop it. The Veteran reported that he was having difficulty concentrating in school due to his housing instability and economic stressors. The Veteran's Vet Center counselor noted in his May 2010 letter that the Veteran was struggling to stay in school and had strained relationships with classmates. The Veteran testified at his July 2010 hearing that he had stopped pursuing his business marketing education because he had recently starting living on his own and therefore needed to pursue employment to support himself. However, the Veteran indicated that he would like to continue his education in the future. A June 2011 vocational rehabilitation record notes that the Veteran had completed one and a half years of college at that time. The Board finds that given the Veteran's ability to successfully complete multiple semesters of higher education and his indication that he would like to continue pursuing his education in the future, the Veteran is not deficient in the area of school, and has not been at any time during the period on appeal. The Board notes that the Veteran was at one point struggling to stay in school and received a failing grade in a class. However, the record seems to reflect that this was due to the Veteran's housing instability and financial problems rather than the Veteran's inability to successfully engage in higher education coursework. The Board also notes that the Veteran's tendency to lose his temper resulted in strained relationships with classmates. However, there is no indication in the evidence that the Veteran was ever disciplined or removed from school due to his behavior. As the Veteran has demonstrated an ability to successfully complete multiple semesters of higher education and expressed his intent to continue his education in the future, the Board finds the Veteran does not have a deficiency in the area of school and has not had such a deficiency at any time during the period on appeal. The Board finds that the Veteran may have a deficiency in the area of work. The Veteran's Vet Center counselor reported in his May 2010 letter that the Veteran was unemployed at that time. At his July 2010 hearing, the Veteran testified that he was last employed in April 2007. He reported that at that time he was fired from his job as a hotel security guard, a position he held for four months, because his employer believed he had a threatening confrontation with another employee. The Veteran also testified that although he was actively seeking employment at the time of his hearing, he was concerned about how he might behave in the workplace because of his anger problems. A June 2011 vocational rehabilitation record noted that the Veteran indicated he wanted a job where he could work alone, because he needed to adjust to being around people in a workplace environment. The Veteran's vocational rehabilitation records reflect that the Veteran secured full-time employment as an events coordinator at an Orlando arena in December 2011. A January 2013 record shows that the Veteran obtained a position with a civilian government contractor, and later records related to scheduling the Veteran's VA examination reflect that the Veteran fulfilled a contract in Afghanistan from January to June 2013. There are no records related to the Veteran's employment status after this time. The evidence of record reflects that the Veteran has had difficulty obtaining employment during the period on appeal. The Board acknowledges that the Veteran recently obtained a contract position and successfully executed a six month contract in Afghanistan, which involved difficult and stressful work. However, the Board will accord the benefit of the doubt to the Veteran and find that the record as a whole reflects that the Veteran has a deficiency in the area of work. Although the Veteran is deficient in the areas of mood and work, he is not deficient in the areas of judgment, thinking, family relations or school. Therefore, he is not deficient in most areas as described by the rating criteria and has not been at any time during the period on appeal. The Veteran's GAF scores ranging from 51 to 65 also do not indicate deficiencies in most areas. As the Veteran has not had deficiencies in most areas at any time during the period on appeal, the Board finds that the criteria for a 70 percent rating have at no time been met. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (holding that a veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration). The Veteran has not had any of the symptoms suggestive of a 100 percent rating at any time during the period on appeal. The Veteran has not had gross impairment in thought processes or communication. The Veteran has consistently denied experiencing any auditory or visual hallucinations, and therefore has not had persistent delusions or hallucinations. The Veteran has never demonstrated grossly inappropriate behavior, has not had a persistent danger of hurting himself or others, and has not had an intermittent inability to perform activities of daily living. The Veteran has not had spatial disorientation or memory loss for the names of close relatives, his own occupation or his own name. The Veteran's GAF scores ranging from 51 to 65 do not indicate total impairment. As the Veteran has had none of the symptoms suggestive of a 100 percent rating and there is no other evidence of total impairment at any time during the period on appeal, the Board finds that the Veteran does not have total social or occupational impairment as a result of his psychiatric disability. The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). 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. 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; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The schedular evaluation for the Veteran's psychiatric disability is not inadequate. The Veteran's reported symptoms are squarely within the anticipated symptoms of the General Ratings Formula for Psychiatric Disabilities. Although the Veteran has endorsed some of the symptoms for a rating in excess of 50 percent, such as inability to establish and maintain effective social relationships, the application of the ratings schedule is not thwarted. There is no reason that mere endorsement of symptoms associated with a higher rating invalidates the balancing test used by the Formula. The Veteran does not argue such and there is no other evidence to suggest that the schedular rating is defeated by the presence of these symptoms. The Veteran merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, supra. The Board acknowledges that the record contains evidence related to the effect of the Veteran's service-connected psychiatric disability on his employability. The Board notes that the Veteran filed a claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). This claim was denied in a July 2009 rating decision. However, the Veteran had previously submitted a withdrawal of his TDIU claim in January 2009. The evidence of record does not show that the Veteran indicated an intent to refile or reopen his TDIU claim at any time after January 2009. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the possibility of staged ratings. The Board, however, concludes that the criteria for a rating in excess of 30 percent for the period prior to August 4, 2009, or in excess of 50 percent on and after August 4, 2009, have at no time been met. Accordingly, further staged ratings are inapplicable. See id. As such, the Board finds that the preponderance of the evidence is against the Veteran's increased rating claim for an initial evaluation higher than 30 percent prior to August 4, 2009, as well as higher than 50 percent on and after August 4, 2009 on a schedular basis, and on an extraschedular basis. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). II. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claim for an increased initial evaluation for his service-connected psychiatric disability. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). 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. Id. The initial rating appeal arises from a granted claim of service connection. Compliance with the first notice element requires notice of the five service connection elements in initial ratings cases: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dunlap v. Nicholson, 21 Vet. App. 112 (2006). Prior to initial adjudication of the Veteran's claim in July 2008, a March 2008 letter fully satisfied the duty to notify provisions, including notice of the degree of disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The Board also concludes VA's duty to assist in obtaining records has been satisfied. The Veteran's service treatment records and VA medical records are in the file. The Veteran's VA vocational rehabilitation records are also in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The RO provided the Veteran with appropriate VA examinations in June 2008, June 2009, and July 2013. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA, records of which are in the file), and there are no records suggesting an increase in disability has occurred as compared to the most recent VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorder since he was last examined. 38 C.F.R. § 3.327(a). The examination reports provide sufficient evidence to apply the ratings schedule and to determine that the schedular rating is adequate to rate the disability. The Veteran contended at his July 2010 hearing that his June 2009 VA examination was inadequate. The Veteran asserted that the duration of that examination was too short, and that the examination report did not accurately reflect his symptoms. The Veteran did not give any specific indications as to why that examination was inadequate. On review, the Board finds all three of the Veteran's VA examination reports to be adequate, well-reasoned, and based on correct facts and a thorough examination. The Board notes that the Veteran was afforded another VA examination in July 2013, and the Veteran did not challenge the adequacy of this most recent examination. The examinations in this case are an adequate basis on which to adjudicate the claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). [Continued on Next Page] ORDER Entitlement to an initial evaluation in excess of 30 percent for an acquired psychiatric disability, to include adjustment disorder with mixed emotions, prior to August 4, 2009, is denied. Entitlement to an increased evaluation of 50 percent, but no higher, for an acquired psychiatric disability, to include adjustment disorder with mixed emotions, is granted on and after August 4, 2009, subject to the laws and regulations governing payment of monetary benefits. Entitlement to an evaluation greater than 50 percent for an acquired psychiatric disability, to include adjustment disorder with mixed emotions, is denied for the entire appeal period. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs