Citation Nr: 1342145 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 06-07 651 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to a rating in excess of 50 percent for generalized anxiety disorder prior to April 5, 2010. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 2002 to April 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which granted service connection for adjustment disorder with depressed mood, rated 30 percent, effective in May 2005. In September 2009 a Travel Board hearing was held before the undersigned; a transcript of the hearing is associated with the record. In March 2010, the Board remanded the case to the RO for additional development. A September 2010 rating decision granted an increased (to 70 percent) rating for the Veteran's psychiatric disorder (re-characterized as generalized anxiety disorder), effective April 5, 2010. An April 2012 Board decision increased the rating for the generalized anxiety disorder for the period prior to April 5, 2010 to 50 percent (but no higher), and denied a rating in excess of 70 percent from April 5, 2010, (and also denied service connection for cervical dysplasia). The Veteran appealed that part of the Board's decision that denied a rating in excess of 50 percent prior to April 5, 2010, to the United States Court of Appeals for Veterans Claims (Court). A July 2013 Memorandum Decision of the Court vacated that portion of the Board's decision addressing the rating for the psychiatric disorder for the period prior to April 5, 2010, and remanded the case to the Board for further proceedings consistent with its decision. FINDING OF FACT For the period prior to April 5, 2010, the Veteran's generalized anxiety disorder is shown to be productive of a disability picture that more nearly approximates that of occupational and social impairment with reduced reliability and productivity, and difficulty in establishing and maintaining effective relationships; her disability picture is without evidence of occupational and social impairment with deficiencies in most areas due to such symptoms as obsessional rituals that interfere with routine activities, illogical or obscure speech, near-continuous panic or depression affecting the ability to function independently and appropriately, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, and inability to establish and maintain effective relationships. CONCLUSION OF LAW Prior to April 5, 2010 a rating in excess of 50 percent was not warranted for the Veteran's generalized anxiety disorder. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (Code) 9413 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Where, as here, service connection has been granted and an initial disability rating and effective date have been assigned (see June 2005 rating decision), statutory notice had served its purpose, and its application is no longer required. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided notice on the downstream issue of entitlement to an increased initial rating, and has had ample opportunity to respond/supplement the record. It is not argued that the Veteran was prejudiced by a notice error or omission. See Goodwin v. Peake, 22 Vet. App. 128 (2008). VA has also made reasonable efforts to identify and obtain relevant records in support of the claim. 38 U.S.C.A. § 5103A (a), (b) and (c). The Veteran has had the opportunity to testify at a hearing before the undersigned in September 2009. The Board notes that in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties: (1) to fully explain the issue and (2) to suggest the submission of evidence that may have been overlooked. Here, during the Board hearing in September 2009, the undersigned indicated that the Veteran's testimony would focus on the issue of entitlement to a higher initial rating for the psychiatric disability, and noted the elements to substantiate the claim found lacking (such as the effect that her psychiatric disability has on her functioning at work and also in everyday activities). The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The representative and the VLJ asked questions to ascertain the nature and severity of the Veteran's psychiatric disability. No pertinent outstanding evidence was identified by the Veteran or her representative. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claim for a higher rating. The RO has obtained pertinent VA treatment records. The Veteran has not identified any additional available evidence for consideration in her appeal. VA has arranged for VA examinations to assess the psychiatric disability. 38 U.S.C.A. § 5103A(d). The Veteran underwent a pre-discharge [from service] VA examination in February 2005 and post-service VA examinations in February 2009 and April 2010, to determine the nature and severity of her psychiatric disability. As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. Legal Criteria, Factual Background, and Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. On a February 2005 pre-service-discharge VA fee-basis (QTC) examination, the Veteran reported that her psychiatric symptoms began in 2004; she reported that she had nightmares, and had difficulty falling, and staying, asleep. She had constant symptoms of crying, and feeling unwanted, hopelessness and insignificance. She stated that her ability to perform daily functions was impaired. Her mind continually raced with thoughts of how she should act in order to avoid being charged with another military offense. On mental status examination, her orientation was within normal limits, and her appearance, behavior, and hygiene were appropriate. Her affect and mood were abnormal with depressed mood, but the depression did not affect her ability to function independently and effectively. Communications were abnormal as she would, at times, get very defensive. Her speech was within normal limits. She reported having 10 to 15 panic attacks per month, with each episode lasting three to four hours. The attacks involved a pounding chest, flushed face, and excessive sweating. She did not have delusions, hallucinations, or obsessional rituals. Her thought processes were appropriate, judgment was not impaired, abstract thinking was normal, and memory was within normal limits. She did not have suicidal or homicidal ideations. The examiner found the Veteran mentally capable of managing benefit payments in her own best interest. Mentally, she occasionally had some interference in performing activities of daily living due to poor socialization. She had decreased motivation for exercise and cleaning her apartment. She had difficulty establishing and maintaining effective work and social relationships because she isolated herself. She had no difficulty understanding commands. She appeared to pose no threat of persistent danger or injury to self or others. The diagnosis under Axis I was adjustment disorder with depressed mood. A Global Assessment of Functioning (GAF) score of 54 was assigned. Vet Center mental health treatment records, dated from 2005 to 2007, show that the Veteran received treatment for a diagnosis of chronic posttraumatic stress disorder (PTSD) with secondary severe depression. A March 2007 letter by a Vet Center psychiatrist notes that the Veteran had symptoms of severe depression, intrusive thoughts, nightmares, intense psychological distress, intense physical reactivity upon exposure to triggers, avoidance of reminders of her trauma, markedly diminished interest in significant activities, restricted range of affect, feeling detached from others, sleep disturbance, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. The psychiatrist noted that although the Veteran had been able to work, her difficulties with concentration and excessive irritability had necessitated some accommodation on the part of her supervisor. Her avoidance behaviors were extreme (for example, she would shop for groceries at times when the store was not busy), and she would spend time alone in her apartment. She had panic attacks when reminded or cued to circumstances that resembled her trauma. The panic attacks would occur about 10 to 15 times a month, and were disabling. She attempted to cope by obsessive cleaning of her apartment and by going to bed and sleeping (hiding) under the covers. She had no social life and feared any kind of relationship with others. An August 2008 VA mental health admissions evaluation note reveals that the Veteran had recently relocated to the area, and as a result had a limited support system, financial concerns, and ill parents with whom she now lived and for whom she cared. She reported that she had been struggling with anger, unstable mood (with crying spells), depressed mood, sleep disturbance, poor concentration, and intrusive thoughts/memories of allegations of sexual misconduct. She had also been having some somatic complaints. On mental status examination, she was neatly dressed, had good eye contact, grooming, and hygiene. She was cooperative. She was oriented times four. Her mood was sad with tears at times. She presented a good range of emotions, including brightness when speaking of her animals and painting. Her affect was inconsistent with what she described at times, as if to cover up the severity of her depression. Her thought processes were organized. She was able to concentrate. She had good insight for problems and situations. Her judgment was fair to good. It was noted that three days earlier she had thoughts of wanting to die through passive means. The Axis I diagnoses were PTSD secondary to MST [military sexual trauma] of harassment and allegation of sexual misconduct, and depression. A GAF score of 32 was assigned. An October 2008 VA psychiatry outpatient progress report indicates that the Veteran presented with PTSD symptoms secondary to military harassment starting in 2002. She reported that she had been struggling with anger and intrusive memories. She had been planning to participate in the "Debutants program in DC" but thought that she would be asked about her discharge from the military, and would have to "deal again with another rejection." She denied suicidal or homicidal ideation. On mental status examination, the Veteran was described as neatly dressed, with good eye contact and good grooming and hygiene. She was cooperative. Her mood was sad with tears at times. Her affect was inconsistent with what she described at times, as if to cover up the severity of her depression. Her thought processes were organized, and she was able to concentrate. She had no perceptual disturbances. Her insight was good and her judgment was fair to good. The Axis I diagnoses were PTSD secondary to harassment/allegations of sexual misconduct, and adjustment disorder with depressed mood. A GAF score of 51 was assigned. Similar clinical findings were noted in a November 2008 psychiatry outpatient progress report, but the assigned GAF score was 57. A December 2008 VA mental health counseling report indicates that the Veteran related that she was feeling a little better with her medications but that she also had been feeling very "stressed out" due to demands of her parents and sibling antagonism with her brother. On a January 2009 VA psychiatry outpatient visit, the Veteran reported that she was "feeling overwhelmed and depressed." She stated that her parents and her brother had been very "mean" to her and were not appreciative of her efforts to take care of her parents. For the previous two weeks, she had been feeling very low and emotionally very sad. She had decreased sleep and appetite. There was no report of suicidal or homicidal ideation. She did not report symptoms of mania, psychosis, PTSD, or phobia. She reported that she was compliant with her medications. On mental status examination, she was alert and oriented times three. Her hygiene and grooming were described as fair. She was cooperative and had good eye contact. Her mood was anxious, related, and appropriate. Her affect was full range, of normal intensity, and labile. Her speech was spontaneous, and of normal rate, rhythm, tone, and volume; there were no circumstantialities, or signs of frontotemporal dementia noted. She did not report any suicidal or homicidal ideations. Her insight and judgment were fair. A GAF score of 57 was assigned. On a February 2009 VA examination, the Veteran stated that she felt she was emotionally better prior to her relocation to the area because she had socialized more with friends after her military discharge. Since the move, she did little socializing because most of her friends were married and did not want to socialize without their husbands. She moved to the area to provide a home for her disabled parents. She stated that recently she had not been getting along well with them. On mental status examination, she was fully alert and oriented in all spheres. Her appearance was neat and clean. Her speech was normal in rate, rhythm, and volume, and the content was logical and goal directed. Her mood was depressed about her brother making snide comments to her over the internet (monthly) regarding her military discharge. She had nightmares about her accusers in the Navy trying to kill her, or about seeing some of her accusers in her nightmare. She felt irritable with work subordinates. Her affect was full in range, well related and somewhat tearful when discussing mood and military discharge. She denied hallucinations and delusions. There was no evidence of a psychotic process or core. She related that in January 2009 her employer told her to go to the VA emergency room when she was crying after thinking about being hit by a truck. She stated that she thought about killing herself in non-specific ways about five times yearly. She had no cognitive or memory deficits. She had normal intelligence, fair insight and unimpaired judgment. The Axis I diagnosis was adjustment disorder with depressed mood. The GAF score assigned was 70. The VA examiner opined that it was less likely than not that the Veteran had an increase in her adjustment disorder with depressed mood in reaction to anything that occurred in the military. Rather, it was as likely as not that she had a mild increase in her adjustment disorder with depressed mood in reaction to giving up her friends in order to take on the burden of buying a house for her disabled parents in order to provide a home for them. It was as likely as not that the symptoms of this increase in adjustment disorder with depressed mood were increased irritability with subordinates at work, increased nightmares, and increased difficulty getting along with her disabled parents. On a subsequent February 2009 VA psychiatry outpatient progress report, the Veteran related that her mood had been stable. After the visit of her brother and his family, they had had problems and now she felt more relaxed. She enjoyed taking her dog on hikes and painting on canvas. She had been compliant with medication. On mental status examination, she was oriented times four, and was neatly dressed with good grooming and hygiene. She was cooperative, with good eye contact. Her mood was anxious, her affect was labile, and her speech was fluent and spontaneous with normal rate, volume, and rhythm. Her thought processes were organized and she was able to concentrate. Her insight was good and judgment was fair to good as she minimized symptoms in order to be strong. The Axis I diagnoses were PTSD secondary to harassment/allegations of sexual misconduct (in the military), and adjustment disorder with depressed mood. The GAF score was 57. VA psychiatry outpatient progress reports in March 2009, April 2009, and May 2009 reflect similar clinical findings as those reported in February 2009, including GAF scores of 57. On her March visit, she reported that her mood had been stable, with the exception of one occasion when talking about her traumatic event. On her April visit, she reported her mood was good, although she still felt depressed and sometimes hopeless and worthless. She denied having any suicidal ideations, and she stayed busy with her three jobs and taking care of her disabled parents. On her May visit, she related that a recent trip was good for her because she resumed a relationship with an old school friend. She described her mood as good and denied any of the usual feelings of hopelessness and worthlessness. On a May 2009 addendum report, a depression screen was performed, and was suggestive of mild depression. On a June 2009 VA psychiatric follow-up visit, the Veteran reported that her mood was okay but she had been depressed lately due to work circumstances. She stated that she was not happy in the workplace, as her subordinates had been talking about her and filing complaints. She stated that she was not sure why she was being targeted as she has tried to be fair and believed herself to be a very kind and generous person. She stated that she was able to complete her tasks at work, and continued to get above average evaluations from her supervisors. However, the behavior of her co-workers had affected her drive to go to work and at times she hated going to work. Her sleep had been okay, as she was getting six to eight hours of sleep a night. She has had two nightmares in which people were trying to murder her. She denied suicidal or homicidal thoughts. She had plans to take a trip in July to visit with friends. She was compliant with medications. On mental status examination, the Veteran was noted to have good grooming, hygiene, and eye contact. Her mood appeared euthymic, and her affect was of normal range and intensity, and appropriate. Her speech was of normal rate, tone and volume, as well as fluent and spontaneous. Her thought processes were linear, goal directed, and logical. There were no delusions, paranoid ideations, obsessions, or compulsions. Her cognitive abilities were grossly intact. Her impulse control was good and judgment and insight were intact. The diagnoses were PTSD secondary to harassment and allegations of sexual misconduct, and adjustment disorder with depressed mood. A GAF score of 61 was assigned. VA mental health counseling notes indicate that in July 2009 the Veteran reported feeling a little better with medications, but feeling overwhelmed due to incidents at work that were similar to military accusations. She was also seen after returning from a vacation, where she reconnected with old military friends. She became teary at times when speaking of her parents getting older and their eventual death, which would leave her unsupported emotionally. She continued to engage in numerous activities including some with friends, but she was aware this area needed to be developed further. Then, in August 2009 she reported that her depressive symptoms had increased, with irritability and a lack of energy and interest in activities like painting. She continued to engage in numerous activities including some with friends. On a subsequent August 2009 VA psychiatry outpatient consult, the Veteran reported that she had not been able to sleep for more than three hours for the past week. She denied suicidal or homicidal thoughts, and stated that she lived for her dog and cat and was hopeful for the future. On mental status examination she was alert, and oriented in time place and person. She had good grooming, hygiene, and eye contact. She was cooperative. Her mood appeared euthymic. Her affect was of normal range and intensity, and appropriate. Her speech was normal, fluent, and spontaneous, and of normal rate, tone, and volume. Her thought processes were linear, goal directed, and logical. She had good impulse control. Her judgment and insight were intact. A GAF score of 61 was assigned. In September 2009 and October 2009 VA psychiatry outpatient progress reports, the Veteran complained that she continued with difficulty sleeping. She had an irregular work schedule where she worked from 3:00 p.m. to 2:00 a.m. and arrived home around 3:00 a.m.. The physician indicated that the work schedule may have produced the shift in the Veteran's sleeping patterns. The Veteran stated that because of financial concerns, she could not change her work schedule to a day shift. On mental status examination, she was alert, and oriented in time, place, and person. Her grooming, hygiene, and eye contact were good. Her speech was normal, fluent, and spontaneous, and had normal rate, tone, and volume. She was cooperative. Her thought processes were linear, goal directed, and logical. She had no suicidal or homicidal thoughts. There were no delusions, paranoid ideations, obsessions, or compulsions. Her cognitive ability was grossly intact. She had good impulse control. Her judgment and insight were intact. In October 2009, symptoms of hypomania were reviewed, but the Veteran denied any symptoms. GAF scores of 61 were assigned. A November 2009 VA psychiatry outpatient progress report indicates clinical findings very similar to those of previous months, but her mood appeared "down" (she was very sad about her dog who had been diagnosed with lymphoma), and a GAF score of 55 was assigned. In a January 2010 VA telephone contact note, the Veteran requested a refill of medication. She denied any suicidal or homicidal ideations and reported a stable mood at that time. In February 2010 VA psychiatry outpatient progress reports, the Veteran reported that she began a new job since the end of November 2009, which was of a supervisory level. Her shift hours had changed somewhat, and she also noted a second job on Saturdays. She felt that she did not sleep enough. Symptoms of hypermania were reviewed, and she denied any symptoms. She continued to live with and take care of her two disabled parents. She was compliant with medication. On mental status examination, she was alert, and oriented in time, place, and person. Her grooming, hygiene, and eye contact were good. Her speech was normal, fluent, and spontaneous, and had normal rate, tone, and volume. She was cooperative. Her thought processes were linear, goal directed, and logical. She had no suicidal or homicidal thoughts. There were no delusions, paranoid ideations, obsessions, or compulsions. Her cognitive ability was grossly intact. She had good impulse control. Her judgment and insight were intact. A GAF score of 60 was assigned. Similar findings were recorded on a March 2010 VA psychiatric outpatient progress note, with a GAF score of 61 assigned. When evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. Generalized anxiety disorder is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9413. 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). Accordingly, the evidence considered in determining the level of impairment from generalized anxiety disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9413. Instead, 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)). The Veteran's generalized anxiety disorder has been rated 50 percent under 38 C.F.R. § 4.130, Code 9413, and the General Rating Formula for Mental Disorders (General Formula) from May 2005 (when service connection was established) to April 5, 2010. Under the General Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A higher rating of 70 percent is assigned for 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. 38 C.F.R. § 4.130. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV at 32. GAF scores ranging from 61 to 70, for example, reflect 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 generally functioning pretty well, has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). For the period considered in this appeal - from the effective date of service connection in May 2005 to April 5, 2010 - the pertinent record, which is primarily comprised of VA treatment records and VA examination reports, shows that the assigned GAF scores mostly ranged from 51 (indicating moderate disability) to 61 (indicating mild disability), with one score of 32 (indicating major impairment in several areas) and one score of 70 (indicating mild disability). With the exception of the scores of 32 and 70, the scores have remained relatively static within the range of 51 to 61 throughout the period considered in this appeal. Accordingly, a single evaluation, rather than "staged ratings" as will be further discussed below, is proper. In any event, a disability rating depends on evaluation of all the evidence, and a VA examiner's classification of the level of a psychiatric impairment by words or by a GAF score is to be considered, but is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126. In evaluating the evidence, the Board concludes that for the period considered in this appeal, the records show that the Veteran's psychiatric symptoms have affected her everyday life and her ability to function to a degree that more nearly approximates the schedular criteria for a 50 percent rating, and no higher, under Diagnostic Code 9413. That is, the evidence shows that the psychiatric symptomatology was of such extent, severity, depth, and persistence as to have been productive of occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. It was frequently described in the medical record how the Veteran's psychiatric disability impacted her mood at work, such that crying spells resulted in supervisors directing her to take breaks and even to seek emergency treatment on one occasion. Also, the Veteran's social isolation, particularly after she relocated to another state to take care of her elderly, disabled parents, was commonly reported in the records. Despite her difficulty in making friends, she evidently maintained friendships, as it was recorded that she had taken a trip back to her former home to visit friends and that she continued to engage in activities that included friends. This fact is more reflective of the criteria for a 50 percent rating (i.e., difficulty in establishing and maintaining effective work and social relationships) than the criteria for a 70 percent rating (i.e., inability to establish and maintain effective relationships). Additional examples from the clinical findings, largely summarized above, that show the Veteran's symptoms were more consistent with the symptoms - in terms of type and degree - that are contemplated by the criteria for a 50 percent rating rather than the criteria for a 70 percent rating are as follows. One of the most persistent symptoms of the Veteran was a disturbance of mood. A few times on progress notes the Veteran reported that her mood was good, but a depressed mood was a frequent problem for her. Panic attacks were also noted to be frequent (more than once a month) prior to her discharge from service, and in treatment records of the Vet Center until 2007, but after that period they did not appear to be problematic. Her speech was typically within normal limits, and she was generally noted to have no delusions, hallucinations, or obsessional rituals. She had no difficulty in understanding commands, and her memory was not found to be deficient. Excessive irritability and difficulty with concentration were noted by the Vet Center, but she was still able to maintain her job albeit with some accommodation by her supervisor. Later, in June 2009, it was noted she continued to receive above average evaluations from her supervisors. In November 2009, she herself attained a job at a supervisory level. Despite the reports of irritability especially at work, and depression due in part to work circumstances, the record shows the Veteran had good impulse control. Although she reportedly had no social life, she was not without friends and she had a fairly good relationship with her parents for whom she cared (she indicated once that they were her emotional support). Even on the occasions (such as in January 2009) when she felt "overwhelmed" in caring for her parents who reportedly were "mean" to her at times, and she felt low and sad with decreased sleep, she remained oriented and alert, kept proper hygiene/grooming habits, and maintained her job. She also remained compliant with her medications and did not report suicidal or homicidal ideation. As noted on February 2009 VA examination, her socialization with friends was minimal, if at all, after she relocated to care for her parents. Nevertheless, the examiner assigned a GAF score of 70, denoting mild social (and occupational) impairment. A depression screening in May 2009 was also suggestive of a mild level of severity. Additionally, in 2009 she traveled twice to visit with friends, and records in July 2009 and August 2009 indicate that she continued to engage in activities with friends. In short, such findings do not, in the Board's judgment, typify the criteria for a 70 percent rating under Code 9413. Thus, a rating in excess of 50 percent is not warranted prior to April 5, 2010. On the basis of the findings on the VA examinations and outpatient treatment, the severity of the Veteran's generalized anxiety disorder approximates the criteria for a 50 percent schedular rating, and the record for the period in question reflects few, if any, symptoms of a psychiatric disability that typify the criteria for a 70 percent schedular rating. As previously described, the VA records of examination and treatment do not tend to show any objective evidence of obsessional rituals that interfered with routine activities, illogical or obscure speech, near-continuous panic or depression affecting the ability to function independently and appropriately, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, inability to establish and maintain effective relationships, or any comparable symptoms of the same severity. Of such criteria, a depressed mood was one of the most common and ongoing symptoms experienced by the Veteran, and it clearly was productive of substantial impairment, as shown by her need to take breaks intermittently from work. Nevertheless, she was still shown to have the ability to function independently, appropriately, and effectively. For example, the evidence does not show her symptoms were severe enough to jeopardize her employment, only that her supervisor accommodated her on some occasions. Moreover, she herself eventually attained a supervisory level job. Also, health care providers noted her ability to "cover up" or mask the severity of her depression, in the face of maintaining her concentration and having organized thought processes and fair to good judgment. The record shows few, if any, of the symptoms under the criteria for a 70 percent rating or any other symptoms of similar nature or gravity. As previously noted, the Veteran was consistently alert and oriented, and she took care of her personal appearance (she was generally neatly and carefully dressed). Although she reported some suicidal feelings a few times a year, the symptoms did not interfere with her routine activities. She was capable of performing activities of daily living, to include maintaining more than one job and caring for her disabled parents after she relocated to be near them (they lived with her). Frequent complaints included sleep problems, social isolation, irritability, and depressed mood, but the symptoms did not affect her ability to function independently. Again, she notably took on the responsibility for caring for her two parents, in addition to ably performing occupational tasks on a regular basis (including in a supervisory role at one point) and activities of daily living on her own part. This demonstrates that she was functioning at a fairly high level. The VA examiners and mental healthcare providers have been in near unison in characterizing the level of the Veteran's overall social and occupational impairment from her psychiatric disability as being in the range of mild to moderate. The lone, isolated GAF score of 32 in August 2008 was not explained in the context of the clinical findings at that time, which were not consistent with such a low score. For example, the symptoms were not reflective of any impairment in reality testing or communication and were not illustrative of major impairment in several areas, such as work, family relations, judgment, thinking or mood (e.g., depressed woman avoids friends, neglects family, and is unable to work). Instead, at that time she had good insight, fair to good judgment, and organized thought processes. She was also oriented times four. Perhaps the symptoms that stood out then, which were seen as productive of a GAF score of 32, were her reports of anger, unstable mood, and a recent episode of suicidal ideation, but the symptoms actually observed clinically did not depict such a severe level of disability. Given the foregoing, the Board finds that the symptomatology from the Veteran's psychiatric disability is more consistent with the criteria for a 50 percent schedular rating under Diagnostic Code 9413. Finally, although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). For the period prior to April 5, 2010, in comparing the Veteran's generalized anxiety disorder level and symptomatology to the Rating Schedule, the Board finds that the level of disability shown is encompassed by the Rating Schedule criteria. A higher rating of 70 percent is provided for a more severe psychiatric disability. Furthermore, the Veteran has not been hospitalized for her disability, and VA examination reports indicate that she has maintained gainful employment throughout the period (advancing to a supervisory position, see February 2009 treatment record), was able (for financial reasons) to work a less desirable shift, and even worked more than one job. In short, the evidence does not show a marked interference with employment. In light of the foregoing, the assigned schedular rating of 50 percent is adequate, and referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is not required. ORDER The appeal seeking a rating in excess of 50 percent for generalized anxiety disorder for the period prior to April 5, 2010 is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs