Citation Nr: 1339099 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 10-19 615 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUES 1. Entitlement to a rating in excess of 30 percent for the service-connected anxiety disorder not otherwise specified (NOS), with posttraumatic stress disorder (PTSD) features and alcohol abuse. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) by reason of service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from July 1965 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from a November 2009 rating decision issued by the RO. The Veteran testified at a hearing held at the RO before the undersigned Veterans Law Judge at May 2012. The issue of entitlement to a TDIU rating is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The level of impairment from the service-connected anxiety disorder is shown to more closely approximate a disability picture manifested by occupational and social impairment with reduced reliability and productivity CONCLUSION OF LAW The criteria for the assignment of a rating of 50 percent, but no higher, for the service-connected anxiety disorder NOS and its associated features, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.130 included Diagnostic Code 9413 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper VCAA notice 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. The Board notes that 38 C.F.R. § 3.159 was revised in part, effective May 30, 2008. See 73 Fed. Reg. 23,353-23,356. The third sentence of 38 C.F.R. § 3.159(b)(1), which stated that "VA will also request that the claimant provide any evidence in the claimant's possession that pertains to the claim," was removed. This amendment applies to all applications pending on, or filed after, the regulation's effective date. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g. Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sum nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was sent a letter in October 2009, prior to the rating decision at issue, which explained how VA could help him develop evidence in support of his claim. The October 2009 letter also explained that in order to receive a higher rating the Veteran needed to show that his disability got worse. It also explained the general manner whereby VA assigns ratings and effective dates for service connected disabilities. VA also must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record evidence including service treatment records, VA treatment records, treatment records and letters from the Veteran's private therapist, and a transcript of the Veteran's testimony at the May 2012 hearing. The Veteran and his representative submitted written statements after the SOC was issued, but these statements were largely duplicated by their hearing testimony, so remand to the RO to consider these statements is unnecessary. He has not identified any relevant information to his claim which was not obtained. The Veteran was afforded a VA examination in August 2011 that adequately documented the symptoms and functional effects of the service-connected anxiety disorder. The Veteran also had a prior VA examination in September 2008, that was about a year before he filed this increased rating claim, and again in March 2009 about six months prior to his claim. The Board finds that the requirements of VCAA have been met in this case. Increased Rating The Veteran contends that the symptoms of his anxiety disorder (also diagnosed as PTSD) are more severe than is contemplated by the currently assigned 30 percent disability rating. Disability ratings are determined by applying criteria that are set forth in the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4). Ratings are based on average impairments of earning capacity resulting from particular diseases and injuries and the residuals thereof in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities are described utilizing diagnostic codes set forth in 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where entitlement to compensation for a service-connected disease or injury already has been established and entitlement to an increase in the disability rating is at issue, the present level of disability is of primary importance. See, e.g., Franciso v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). The service-connected anxiety disorder is evaluated under 38 C.F.R. 4.130, Diagnostic Code 9413. Note that PTSD, Diagnostic Code 9411, is rated using the exact same criteria. Recharacterization of the Veteran's disability as PTSD in accordance with more recent examination findings would not change the rating or analysis. All mental disorders other than eating disorders are rated pursuant to a General Rating Formula for Mental disorders which is found at 38 C.F.R. § 4.130. A rating of 30 percent is assigned when the Veteran exhibits occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A rating of 50 percent is assigned when the Veteran exhibits 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 rating of 70 percent is assigned when the Veteran exhibits 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 work like setting); inability to establish and maintain successful relationships. A rating of 100 percent is assigned when the Veteran exhibits 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. Id. In September 2008, about a year prior to this claim, the Veteran was afforded a VA examination in connection with his initial claim for service connection for a psychiatric disorder (claimed as PTSD). At that time, he reported having symptoms of disturbed sleep and anxiety, in addition to physical problems including hypertension and hyperlipidemia. He was working driving a propane truck and had had this job for many years, but was anticipating retirement within the next year. At the examination, the Veteran reported feeling "not bad." He reported avoiding war-related news programs and having trouble sleeping. He had nightmares about a friend who died in Vietnam. On examination, the Veteran was noted to be pleasant and to appear his stated age. He was neatly and casually attired, well groomed, and exhibited good eye contact. He was polite in manner. He was alert, and there were no apparent motor abnormalities. Speech was normal, and he was fully oriented. Memory was not formally assessed, but seemed grossly intact. The Veteran was attentive and focused during the interview. His mood seemed appropriate, and his affect had a full range. There were no abnormalities of thought content, thought processes, or perception noted. Insight and judgment seemed adequate. The Veteran denied having any current suicidal or homicidal ideation and any significant history of suicide attempts. He reported being able to maintain basic personal hygiene and activities of daily living. The Veteran was administered the Beck Depression Inventory (BDI), and his score was consistent with a mild to moderately depressed mood. Symptoms reported by the Veteran included those of intrusive recollections of his wartime experiences including disturbing dreams and memories. He became very upset when exposed to reminders of Vietnam. He sometimes felt emotionally numb or unable to express loving feelings. He reported having consistently had trouble falling and staying asleep. He often was irritable or had angry outbursts, especially while driving. He was sometimes hypervigilant and easily startled. The Veteran was diagnosed with insomnia and given a global assessment of functioning score (GAF) of 80, denoting that if symptoms are present they are transient and expectable reactions to psychosocial stressors and no more than slight impairment in social or occupational functioning. In December 2008, the Veteran's therapist, a licensed marriage and family therapist (LMFT), wrote that the Veteran had PTSD and that his symptoms included survivor guilt, depression, aggressive outbursts, social isolation, flashbacks and avoidance of reminders of Vietnam. She also submitted what appeared to be an initial assessment form that documented that the Veteran had reported these symptoms in addition to difficulty sleeping and low self esteem. The Veteran reported that, when frustrated, he sometimes became suicidal or homicidal, but had never acted on these feelings. Sometimes he would throw and break things when he got angry, but would then regret his actions. At the assessment, he exhibited appropriate behavior and speech. He reported memory and concentration difficulties and episodes of depression. The examiner noted that he experienced a great deal of "road rage" that presented difficulties for him as a professional truck driver. In January 2009, this therapist wrote a second letter. She reiterated that she had diagnosed the Veteran with PTSD. His symptoms included those of distressing dreams and memories and survivor guilt. He avoided responsibility and chose a job that he was able to do alone. She felt he had a GAF score of 55, which she stated reflected that he had difficulty with social and work related interactions and had longstanding issues that significantly impacted his ability to maintain friendships and work relationships. The treatment records for the period from November 2008 to February 2009 noted symptoms of episodes of mind racing, difficulty sleeping with distressing dreams, bad moods, social isolation and avoiding crowds, survivor guilt, episodes of depression and avoiding responsibility. The Veteran's girlfriend wrote in a letter that the Veteran seemed unable to give or receive affection. He sometimes got depressed over small things. He would display sadness and guilt about his friend who died in Vietnam. He had nightmares and road rage. She felt the Veteran also drank too much. The Veteran was afforded a second VA examination in March 2009. The Veteran arrived about an hour early for his appointment. He was casually and appropriate dressed with good hygiene. Psychomotor activity was generally normal as was speech. His affect was restricted, and he was somewhat tearful at times. He described his mood as irritable and depressed at times. His affect was content appropriate and mood congruent. He maintained eye contact and was open and cooperative. The Veteran reported that he was twice divorced and in an on again off again relationship with his girlfriend, who seemed to want more closeness than he could provide. He had very good relationships with his children and grandchild. His relationships with his siblings were fine. He was still employed driving a propane truck, but was going to reduce his work to part time because he had been doing it a long time and did not enjoy it anymore. He had a steady and stable work history. He felt that it was not fun going to work and he wanted to enjoy life more and not work until he died. He got along with people at work. At the examination, the Veteran reported having intrusive thoughts and dreams and guilt about his friend who died in Vietnam. His nightmares occurred every one or two weeks. He felt angry and scared when exposed to reminders of Vietnam such as helicopters. He was able to talk about his Vietnam experiences with other combat Veterans, but otherwise he did not talk about it. He avoided crowds. He felt detached and emotionally distant from others. He had lost interest in many activities. He had insomnia and complained of irritability, angry outbursts, difficulty concentrating and hypervigilance. He reported having good days and bad days, but got aggravated very easily. He had lost weight recently because he had not been bothering to go out to eat and would not cook for himself. He reported that he thought about death all the time and sometimes thought that life was not worth living, since he had so many friends who had passed away. He sometimes had thoughts about driving into a tree, but had no intent or plan to do so. He denied having thoughts about hurting others. He did not like driving in unfamiliar areas. He drank excessively on weekends. He sometimes felt he saw shadows out of the corner of his eye. On examination, the Veteran was noted to be alert and fully oriented. His attention was not impaired during the examination. He was not tangential or circumstantial. His thought content was appropriate to the interview context and was not obsessional or delusional. There was no evidence of obsessions, compulsions, ideas of reference, hallucinations, delusions, phobias, social fears, excessive worry, hypomania, mania, panic attacks or agoraphobia. He had some posttraumatic stress symptoms, depressed mood and adhedonia. There was some suicidal ideation, but no intent or plan or current homicidal thoughts. There was ongoing alcohol abuse, but no evidence of social isolation. Insight and judgment were adequate. The Veteran was generally able to take care of his activities of daily living. He had interests and hobbies including a bowling league, but stated that he did not know what fun was. He had a few Veteran friends and some from his bowling league. He saw his friends weekly. He stated that he liked certain people, but did not want to bother with others. He reported having difficulty completing tasks in his everyday household routine such as doing dishes. The examiner diagnosed anxiety disorder NOS with features of PTSD, depressive disorder NOS, and alcohol abuse, and assigned a GAF that the examiner explained reflected a moderately severe level of impairment. VA treatment records reflect that the Veteran sought psychiatric treatment beginning in August 2009 at the recommendation of his therapist. Symptoms noted at that time included intrusive thoughts, nightmares, hypervigilance, and feelings of detachment. Sometimes he thought he saw shadows in his peripheral vision when he was trying to go to sleep. There was difficulty concentration, poor judgment with regard to alcohol use, sad or depressed mood, anger or irritability, flat or constricted affect, anxiety, and labile mood. The Veteran reported that he was miserable every day. He had retired. He was referred to a psychiatrist who first assessed him in September 2009. Symptoms reported were consistent with what the Veteran had previously reported. He was prescribed medication for nightmares, which he later reported helped with this symptom. Later he was also prescribed an antidepressant. The assessment was that of moderate impairment. In October, he reported that he was enjoying life and retirement and that his anxiety symptoms were better. The Veteran continued in therapy. He reported that he had to leave his girlfriend's house because it was near a gun club and the sounds upset him. He reported situations of anxiety and anger such as being stuck in a traffic jam. Sometimes he felt like someone was jumping on him in bed. His marriage and family therapist wrote another letter for him in November 2009. She stated that the Veteran had symptoms including memory loss for the names of close relatives, impaired impulse control resulting in unprovoked outbursts and irrational violent behaviors, difficulty establishing and maintaining close personal and interpersonal relationships, panic attacks several times per week, difficulty understanding and responding to complex work tasks, unexplained anxiety, lack of motivation and enjoyment in daily life, nightmares, alcohol abuse, and anger. She stated that the Veteran stopped working due to PTSD at the recommendation of his doctor. The Board notes that many of the assertions made in this letter are not supported by any treatment records and are directly contradicted in some respects by the Veteran's psychiatric treatment records and statements that he made to the VA examiners. For example, in October 2009, the Veteran's psychiatrist wrote that the Veteran reported that he was "enjoying life" and "enjoying retirement" and "[did] not think he [got] too depressed." While his therapy records established that the Veteran had fears that he would react violently in some situations, he did not actually engage in violent behavior and would avoid conflict by taking a walk. The records from his psychiatrist also revealed that the Veteran was still working part time for a propane company in 2010 and felt that working was helping him. Subsequent treatment records from the Veteran's psychiatrist reflect that his depressive symptoms had largely abated, but he still had problems with symptoms including anxiety, excessive worry, and flashbacks. GAF scores were generally in the mid-50s. This generally reflects moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Veteran's therapist wrote another letter in August 2011. The Veteran's therapist claimed that the Veteran had to stop working due to PTSD symptoms. These symptoms included difficulty thinking clearly especially when under stress, difficulty controlling his anger when he thinks someone is standing or walking behind him, concentration and memory difficulties that caused him to forget the date, social isolation, difficulty trusting people, and problems with impulse control. She wrote that the Veteran physically attacked people who came up behind him, but the Board notes that there are no treatment records substantiating this contention and the Veteran has not contended that he engaged in any type of physical violence. The Veteran was reexamined by VA in August 2011. At that time, he reported that he avoided spending time at his girlfriend's house because it was near a gun club and he felt that the noise gave him flashbacks of Vietnam. He reported he had no loving feelings and spent less time with his girlfriend than he had in the past. He had a few friends that he saw regularly. He got along well with family members and loved spending time with his children and grandchildren. He retired from his job as a truck driver in 2009. At times, he thought of crashing the truck, but thoughts of his family stopped him from considering suicide more seriously. He had a good work ethic, and there were never any issues with him at work. On a typical day, the Veteran would watch television, go out walking, and do errands. He reported having some lack of motivation to do other things. He occasionally did volunteer work with Veterans. He was seeing a therapist and a psychiatrist. The Veteran used to have an alcohol problem, but had recently cut back on drinking. The examiner felt the Veteran did meet the criteria for PTSD. Symptoms included distressing thoughts and dreams about Vietnam, flashbacks, avoidance, feelings of detachment, and a sense of a foreshortened future. He had sleep troubles, irritability or outbursts of anger, and an exaggerated startle response. Other symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, impaired abstract thinking, and suicidal ideation. In addition to PTSD, she diagnosed a depressive disorder and alcohol abuse. She assigned a GAF score of 60, denoting the less severe end of the spectrum of symptoms that would be considered moderate in nature. She assessed the Veteran as having 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, or symptoms controlled by medication. The Veteran testified about his symptoms at a hearing in May 2012; he and his representative also submitted written statements that covered some of the same material. His representative also provided testimony at the hearing although he was not sworn in. The Veteran's representative said that he witnessed that the Veteran had an exaggerated startle response and had almost struck him when he came up behind him. The representative witnessed another incident when an elderly lady came up behind the Veteran and he almost physically defended himself against the lady. At times, the Veteran made statements that he would be better off dead to his therapist and to other people including his representative. The Veteran testified that he had survivor guilt. He testified that he lived in a basement apartment like a bunker and slept with a stick near the bed because he was afraid someone would enter the apartment. He preferred to be by himself for the most part, although he went to the VFW sometimes because he could relate to the people there. On one occasion, he chased a car that had cut him off while driving. He did not confront the other driver. He had been in therapy for two and a half years. His ex-wives had told him he drank excessively. He no longer drank as much as he used to because of interactions with medication that he was taking. He used to work driving a hazardous materials truck and would get road rage, so his doctor told him he should stop working. He had difficulty watching his grandson because he felt that he would hurt him. He did not like people behind him or to be in crowds. He had friends who were also combat Veterans that he spent time with. In determining the appropriate rating to reflect the Veteran's disability picture, the Board recognizes that a Veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhausen v. Principi, 16 Vet. App. 436, 442 (2002) . Rather, the criteria ('such symptoms as') provide guidance concerning the severity of symptoms that are contemplated for each rating, in addition to permitting consideration of other symptoms particular to the Veteran. Id. The Board finds that the Veteran's symptoms more nearly resemble occupational and social impairment with reduced reliability and productivity as is contemplated by a 50 percent rating. He had symptoms including depression at times, anxiety, irritability, road rage, flashbacks, hypervigilance, and sleep problems that produced moderate impairment in social and occupational functioning. Notably, his psychiatrist generally assigned GAF scores consistent with moderate impairment, as did the VA examiners who examined the Veteran in March 2009 and in August 2011. This is also consistent with an August 2009 intake assessment at the VA which assessed moderate impairment and a January 2009 letter from his therapist who at that time provided a GAF of 55. Throughout the record, the Veteran's symptoms are most often classified as moderate in nature by the various professionals who have treated and assessed him. These type of moderate symptoms are more consistent with a 50 percent rating. However, the Board does not find that the criteria for the next higher 70 percent evaluation were met. While the Veteran did exhibit suicidal ideation at times, this was generally passive and without intent. The Veteran reported that he did not think more seriously about suicide because of his ties to his family. He reported having good relationships with his children. Although at his hearing in May 2012, he testified that he no longer looked after his grandson due to his irritability, he had reported that he loved spending time with his children and grandchildren in August 2011. He did not exhibit obsessional or ritualistic behavior that interfered with routine activities and he had no communication difficulties. The Veteran did not report panic attacks at any of his VA examinations and treatment records from his psychiatrist do not reference any panic attacks. While the Board acknowledges that, in her November 2009 letter, the Veteran's therapist claimed that he had frequent panic attacks several times a week, this assertion is not supported by any treatment records or any assertions made by the Veteran himself. While the Veteran reported having generalized anxiety symptoms and flashbacks, he did not testify to experiencing panic attacks or tell any of the VA examiners that he experienced panic attacks. He experienced periods of depression, but this was not shown to be near continuous. In September 2008, the Veteran told a VA examiner that he was feeling "not bad." In October 2009, he reported that he was enjoying life and retirement. Some treatment notes from 2010 reflect assessments that the Veteran's depressive symptoms were largely in remission after he started taking medication. Thus, to the extent that the Veteran did have periods of depression, these were interspersed with times when he felt better and was able to enjoy life and retirement. While he was working, he was able to perform adequately despite his feelings of depression and anxiety. He was able to take care of his activities of daily living. The Veteran had an exaggerated startle response that at times nearly led him to react to certain situations violently, but for the most part he was able to recognize and restrain his behavior. He had some difficulties with road rage, but had not actually physically confronted another driver. The Veteran gave no indication of spatial disorientation and was always noted to be adequately clothed and groomed when this was assessed. There was some indication of heightened symptoms during periods of stress, but there is no indication that this significantly interfered with his work abilities prior to his retirement. He had a long term relationship with a girlfriend and some Veteran friends that he saw regularly. He also liked to spend time with his children and sometimes his grandchild. The Board recognizes that in her letters the Veteran's therapist listed symptoms that were more severe. However, her assertions are less probative than those of the VA examiners. Symptoms that she mentioned such as violent behavior and panic attacks were not documented in any treatment records, and the Veteran never described such symptoms to any VA examiner. Rather, he described having episodes of road rage and violent impulses when startled that he was able to control. He described having anxiety, but not panic attacks. The Veteran's therapist claimed that the Veteran's memory and concentration were so impaired that he would forget the date, but the VA examinations documented that he was fully oriented and had no significant problems with recent memory during any of the interviews. While the Veteran's therapist noted social isolation, the Veteran reported having a long-term girlfriend, some friends, spent time at the VFW, and enjoyed time with his family. The overall severity of the Veteran's symptoms are not so severe as to warrant a 70 percent rating. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). While many of the Veteran's specific symptoms are not listed in the General Formula for Rating Mental Disorders, this formula merely provides examples and a guide for ascertaining the severity of a psychiatric disability. The Veteran's overall picture of moderate impairment in various areas of functioning is contemplated by the assigned 50 percent rating. There is no evidence that the Veteran has ever been hospitalized for psychiatric reasons. While the Veteran testified that his doctor told him that he should not work due to PTSD and his therapist opined that he was unable to work due to PTSD, prior to his retirement the Veteran reported that he planned to reduce his work time because he did not enjoy work any longer and wanted time to enjoy retirement. He did not describe having any difficulties at work other than some problems with road rage. In August 2011, after he retired, he told a VA examiner that he had a good work ethic and never had any problems at work. There is no indication that his PTSD ever materially interfered with his work performance prior to his retirement. He is now retired, so it has no effect on employment. The Board has considered the benefit of the doubt doctrine. However, the weight of the evidence is against the assignment of a rating in excess of 50 percent. ORDER An increased rating of 50 percent, but no more for the service-connected anxiety disorder NOS with PTSD features and alcohol abuse (currently diagnosed as PTSD) is granted, subject to the regulations controlling disbursement of VA monetary benefits. REMAND The Veteran has contended that he stopped working because his doctor told him that he should no longer work because of his service-connected psychiatric disorder, now diagnosed as PTSD. His therapist also opined that the Veteran was unable to work due to PTSD. A claim for an increased rating also encompasses a claim for a TDIU rating when the possibility of entitlement is raised by the record. The contentions of the Veteran and the opinion of his therapist are sufficient to raise this issue. Therefore, it must be initially developed and adjudicated by the agency of original jurisdiction. Accordingly, this remaining matter is REMANDED for the following action: The RO should take appropriate steps to contact the Veteran in order to have him complete an application for a TDIU rating. If the Veteran responds, the RO should undertake to develop the claim and adjudicate it in the first instance. If the claim remains denied, the RO should inform the Veteran of the steps required to initiate an appeal. Thereafter, only if the Veteran timely perfects a timely appeal as to the claim for a TDIU rating, should the case be returned the case to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs