Citation Nr: 1545100 Decision Date: 10/22/15 Archive Date: 10/29/15 DOCKET NO. 10-04 312A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a rating in excess of 70% for major depressive disorder (MDD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Matta, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from December 1990 to May 1991 and from August 1991 to January 1992. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision by the Columbia, South Carolina Department of Veterans Affairs (VA) Regional Office (RO). In April 2012, a Travel Board hearing was held before a Veterans Law Judge (VLJ) who is no longer with the Board; a transcript is in the record. In July 2012, this matter was remanded for additional development (by a VLJ other than the undersigned); it has now been assigned to the undersigned. In June 2015 correspondence, the Veteran was informed of her right to present testimony at another hearing before a VLJ who could participate in any decision made on appeal pursuant to 38 U.S.C.A. § 7107(c) and 38 C.F.R. § 20.707. No response was received, and it is presumed that she does not want another hearing. FINDING OF FACT Throughout, the Veteran's MDD has been manifested by symptoms no greater than productive of occupational and social impairment with deficiencies in most areas; symptoms of MDD productive of total occupational and social impairment are not shown. CONCLUSION OF LAW A rating in excess of 70% for MDD is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130, Diagnostic Code (Code) 9434 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) With increased rating claims, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of her claim prior to the initial adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). A November 2007 letter explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence she was responsible for providing. She has had ample opportunity to respond/supplement the record, and has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. She was afforded VA examinations in March 2007, April 2009, December 2009, and, pursuant to the Board's July 2012 remand, in December 2012. The Board finds the examination reports adequate for rating purposes as they note all findings needed to adjudicate the claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide this matter, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The RO's actions substantially complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's record 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. Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is resolved in favor of the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. The Veteran's MDD is currently rated 70% under 38 C.F.R. § 4.130, Code 9434, based on 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 effective relationships. Id. To warrant the next higher (100%) rating, the evidence must show 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. 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 MDD under 38 C.F.R. § 4.130 is not limited to those symptoms listed in the General Formula. The classification outlined in the portion of VA's Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). 38 C.F.R. § 4.130 (2014). VA implemented DSM-5, effective August 4, 2014. The Secretary of VA, however, has determined that DSM-5 does not apply to claims certified to the Board prior to August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The RO certified the Veteran's appeal to the Board in March 2013. Hence, DSM-IV is still the governing directive for this case. The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100%, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. GAF scores included in the record 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). The DSM-5 contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) because ratings of current functioning will generally reflect the need for treatment or care. The Board notes that while GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record. A GAF score of 31 to 40 reflects some impairment in reality testing or communication, or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. A score of 41 to 50 is assigned where there are 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). A score of 51 to 60 is appropriate where there are 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). A GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). During July 2006 VA treatment, the Veteran's appearance was disheveled and tense; her behavior was restless, her speech aphasic, her attitude attentive, and her affect flat. Her mood was depressed, anxious, irritable, expansive, and angry; her thought process was circumstantial and her thought content was rational. She denied any hallucinations. The social worker noted an increase in depressive symptoms. During October 2006 VA treatment, the Veteran reported an increase in anxiety, poor sleep, sad mood, and panic attacks, as well as an increase in prescribed medications. Her ongoing struggles with migraines worsens her mood. She reported nightmares, vigilance, and intrusive memories, but denied suicidal ideation. On examination, she appeared healthy and well groomed, but tense. Her behavior was appropriate, with no abnormalities noted. Her speech was soft with normal flow, rate, and clarity. Her mood was anxious and dysphoric, affect appropriate with normal range. Her thought process was logical, sequential, and goal directed. Her thought content was relevant with no suicidal or homicidal ideation, no auditory or visual hallucinations, no delusions, and no paranoia. She was alert and oriented to time, place, person, and situation. Her insight, reliability, and judgment were good. Diagnoses included PTSD, panic disorder with agoraphobia, and mood disorder due to migraines, depressed. During additional VA treatment in October and November 2006, the Veteran showed no cognitive impairment and was oriented times three. She had no noticeable concentration, language, or communication difficulties. Both short and long-term memory were grossly intact. She denied suicidal or homicidal ideations, or illogical thoughts. Her social behavior was within society norms. PTSD and panic attacks with agoraphobia were diagnosed and a GAF score of 45 was assigned. During separate December 2006 treatments, GAF scores of 50 and 55 were assigned. During January 2007 treatment, the Veteran reported that headaches followed her panic attacks and that her life was getting "smaller and smaller." She reported not leaving her room often and rarely leaving her home. She felt helpless about her medical problems. On examination, she was neat, clean, and dressed for the weather. She showed no cognitive impairment and was oriented times three. She had no noticeable concentration, language, or communication difficulties. Both short and long-term memory were grossly intact. She denied suicidal or homicidal ideations, or illogical thoughts. Social behavior was within society norms. PTSD was diagnosed and a GAF score of 50 was assigned. On March 2007 VA examination, the Veteran reported that she was working on a PhD in public health online but that she dropped certain classes because she "just could not handle it." She was fired from her last job as a nurse when she ran out of family medical leave. She has been married for seven years and reported a good relationship with her husband. She also has a four-year-old son who she wishes would sometimes go away because she "just cannot cope with him." She sometimes calls her parents to help with her son. She denied having close friends but talks to two out-of-state casual friends once or twice a month. She denied any hobbies or interests; she reported attending church but also leaving services early due to an inability to sit for the whole time. On examination, she was alert, oriented, and attentive. Her mood appeared depressed, with affect restricted and odd at times. Her speech had regular rate and rhythm; her eye contact was good and she was cooperative and pleasant. Her thought content was devoid of current auditory or visual hallucinations and there was no evidence of delusional content. She denied homicidal or suicidal ideation, but reported being physically aggressive with others, including with her father the day before. Her memory was intact for immediate, remote, and recent events. The examiner noted that the Veteran exhibited severe symptoms associated with her depression, PTSD, and panic. She reported anxiety and depressed mood and stated she had thoughts of harming herself about once or twice a week. She reported problems with concentration and slept only four hours at night. She also reported intrusive thoughts of a military sexual trauma (MST) on a daily basis and experienced thoughts associated with being in combat in Desert Storm. She reported nightmares one to two times per month and described an exaggerated startle reaction to unexpected approaches; she was anxious in closed-in spaces and described emotional detachment. She described panic attacks in which she hyperventilates, perspires, has an increased heart rate, feels like losing control, and has tingling in her fingers; these occur daily and can last up to 20 minutes. She goes a few days without changing her clothes or showering, and only showers at her husband's urging. The examiner determined that social adaptability and interactions appear to be severely impaired, as well as her ability to maintain employment. Diagnoses included PTSD, major depressive disorder, and panic disorder. A GAF score of 47 was assigned. On April 2009 VA examination, the Veteran reported that she was having trouble with irritability and concentration in her last job. Her relationship with her husband was good, and she tried to manage her irritability and tendency to withdraw. She reported a fairly good relationship with her two children, even though she sometimes become irritable with them. She denied having any close friends but sees one to two casual friends once a month. She denied any hobbies but reads occasionally. She only attends church once every three months due to the noise and the crowds. On examination, she was alert, oriented, and attentive. Her affect was constricted and congruent with her depressed mood. Her speech was slow, and there was some evidence of psychomotor retardation. Her eye contact was good and she was cooperative and pleasant throughout the examination. Her thought process was logical and coherent; thought content was devoid of auditory or visual hallucinations, but she reported such symptoms in the context of nightmares and flashbacks. There was no evidence of delusional content and she denied thoughts of self-harm. She reported being physically aggressive with another person three weeks before; no information regarding this incident was provided. Her memory was slightly impaired for immediate information, but fairly intact for recent and remote events. She experienced difficulty spelling "world" backwards, which indicated concentration problems. The examiner found that the Veteran exhibited considerable symptoms associated with her PTSD and MDD. She reported daily intrusive thoughts, nightmares a few times a week, and weekly flashbacks. She described psychological and physiological reactivity to stormy weather, certain sounds, or certain smells. She avoids talking or thinking about her trauma, and crowds and certain TV programs depicting trauma. Her affect was constricted and she described emotional detachment from others, as well as decreased interest in activities. She reported sleeping four hours per night and problems with irritability and concentration. She also reported an exaggerated startle response to loud noises or unexpected approaches, and constant feelings of hypervigilance. The examiner determined that her social adaptability and interactions with others, as well as her ability to maintain employment, were considerably impaired. PTSD and MDD were diagnosed, and a GAF score of 52 was assigned. During a February 2008 suicide risk assessment, the Veteran admitted to daily suicidal thoughts because of related back pain, but denied having a plan for how she would kill herself. She admitted to feelings of anxiety, agitation, and hopelessness. Her identified protective factors were good family/friend relationships, a history of coping with stress adequately, and previous positive responses to psychotherapy and psychotropic medications. Her suicide risk was low. According to psychotherapy notes in February and May 2008, the Veteran had no noticeable concentration, language, or communication difficulties. Her short and long-term memory were grossly intact and her social behavior was normal. A GAF of 50 was assigned. In April 2009, the Veteran reported difficulty leaving her home due to anxiety with agoraphobia and depression; the frequency and severity of her anxiety episodes had increased over the last few months. She reported volunteering to chaperone her son's school trip to the zoo but being unable to stay the whole time because of her anxiety attacks. She stayed in her car for 20 minutes trying to "get [her]self together so [she] could drive home" and was unable to engage in any other activity for the rest of the day. She expressed concern about her inability to do things with her family due to anxiety, including watching her son ride his bike outside, or engage in normal activities. She also reported chronic nightmares, flashbacks, isolating, an inability to recall some events associated with trauma, hypervigilance, and an exaggerated startle response. On examination, she was oriented times four. Her mood appeared quiet and her affect occasionally tearful. She denied suicidal or homicidal ideations, hallucinations, or self-mutilating behavior. Her thought process was linear, insight and judgment were good. During the treatment, she had a panic attack accompanied by shortness of breath, trembling, dizziness, numbness in hands, chest pain, and spiked headache pain. She became tearful as she struggled to control her symptoms. A GAF score of 41 was assigned. During June and October 2009 psychotherapy treatment, the Veteran's appearance was well-groomed. Her speech was at a normal rate with spontaneity. Her mood was anxious and depressed, her affect constricted and congruent to content. She denied hallucinations or suicidal or homicidal ideation. On examination, she was oriented times four. Her short and long-term memory were intact. Her concentration was fair, and her impulse control, insight, and judgment were good. Her ability to think abstractly was intact. She reported nightmares a few times a week but denied flashbacks. On December 2009 VA examination, the Veteran reported significant distress since her MST, including intrusive thoughts on a daily basis, nightmares, hypervigilance, and exaggerated startle response. She described anxiety and panic attacks secondary to PTSD and panic attacks two to three times a day. She continued to struggle with depressed mood and feelings of hopelessness. She denied suicidal ideation. She had difficulty with sleep problems initiating and maintaining, getting about three to four hours per night. She is unable to leave the house on occasion due to anxiety and depression. She is easily agitated, more reserved, and has decreased socialization. She denied being hospitalized for psychiatric problems. She reported being married for 10 years and has two sons, with family nearby that helps. She has a few close friends but does not do well with relationships; she does not like to socialize and this is getting worse. She has no hobbies or activities of interest and primarily spends the day taking care of her sons. She reported poor motivation, including maintaining hygiene, and will occasionally skip a few days of showering; she must be reminded by her husband to do so. She has decreased motivation and energy to complete basic cooking and cleaning tasks. On examination, she was oriented times four. Her thought process was linear, history adequate, and affect anxious. Insight was spontaneous, and speech was fluent, grammatical, and free of paraphasia. Her attention and memory were mildly impaired. She did not report any symptoms of psychosis and denied any suicidal or homicidal ideations. Major depressive disorder, PTSD, and panic disorder were diagnosed. Combined, these diagnoses presented a moderate to severe level of impairment of functioning. However, the examiner determined that the Veteran's depressive symptoms alone indicated only a moderate level of impairment in social and occupational functioning. Such symptoms included problems with sleep, decreased levels of energy and anhedonia, variable appetite with recent weight gain, decreased motivation, and decreased socialization. A GAF score of 56 was assigned based solely on those symptoms. In April 2010, the Veteran was hospitalized for worsening depression accompanied with suicidal ideation. Her present stressors included unrelenting migraine headaches and the recent loss of a friend due to cancer. She reported her mood as "sad and depressed," which in turn disrupts her sleep. She reported nightmares that cause her to awaken startled; she also reported flashbacks. With respect to her appetite, she either overeats or eats very little. Her energy was low and her concentration ability was poor. She denied any homicidal ideation, interpersonal relationship conflicts, psychotic symptoms or paranoia, previous use of illicit drugs, or social drinking. On examination, she was cooperative, maintained good eye contact, and exhibited normal motor activity and speech. Her mood was consistent with depressed affect. Her thought process was coherent, and was without suicidal or homicidal ideation. She did not appear to respond to internal stimuli. She was alert and oriented, but her insight and judgment were significantly impaired. Her migraine headaches spontaneously resolved overnight and she reported having had sound sleep. She later reported her mood as "calm." She disclosed a prior history of an eating disorder. By day four of her hospitalization, she gained some insight into realizing that she was taking a large number of medications that interacted with one another and was possibly causing rebound pain. She also realized the need to work past her MST with further counseling. She continued to report further improved mood with no appetite or sleep disturbances and denied having thoughts of harming herself or others. Her GAF score at admission was 35 and by discharge five days later, a GAF score of 60 was assigned. Thereafter, the Veteran participated in scheduled brainwave trainings to address residual pain syndrome and associated brain instabilities. In November 2010, she reported that the last session helped her significantly in that she was able to attend a funeral without fear of panic or headaches. She was also able to take her sons to a parade, a crowded, noisy situation she tended to avoid. During December 2010 VA treatment, the Veteran's appearance was tense, her behavior restless, and her speech spontaneous. She was cooperative toward the examiner. Her mood was anxious, and her affect was normal ranged. She denied hallucinations, or suicidal or homicidal ideations. Her thought process was linear and thought content appropriate. She was oriented times four. Her short and long-term memory were both intact. Her concentration, impulse control, insight, and judgment were good and her ability for abstract thinking intact. Her appetite was adequate and her energy variable. She reported getting out of the house daily. Depressive/anxiety symptoms were present. She denied nightmares, flashbacks, and alcohol or drug use. In January 2011, the Veteran reported that she felt like the crisis mode was over, since her mood was much more stable and even keeled. Her panic episodes were less frequent and less intense and she was able to employ learned tactics and techniques to handle the episodes better, which gave her a greater sense of control. She also reported having fewer migraines. She did not mention any changes in her energy level or to the usual chronic fatigue; however, she appeared in high spirits, relaxed and easy during conversation, and clear-headed. There was no indication she was plagued with fatigue. In March 2011, she was able to tell her husband that she would be fine if he was called into combat. This was an issue that she and her husband have struggled with for the last year because she was unable to handle this previously. Most somatic complaints had diminished considerably. During the April 2012 Travel Board hearing, the Veteran testified that her depressive symptoms included sadness, gloominess, anxiety, and hypo-startle response. She gets anxious quite easily if she is unable to rationalize her surroundings. She also reported many panic attacks. She is unable to participate in activities that she should do as a wife and mother because of her inability to be around people. She also testified that her favorite spot is in the hall closet, which is where she goes when things get too overwhelming. There are days when she can stay at home and not make contact with anyone for several days. Although she has trust issues, she has a good support system with her husband and family. She testified to memory problems, including areas or gaps in time when she does not recall or remember events. However, she is able to concentrate and perform work tasks. Pursuant to the Board's July 2012 remand, the RO arranged for a VA examination in December 2012. On examination, the Veteran reported periods of depressed mood and variable motivation. She also reported intermittent sleep, averaging four and one-half hours per night, an "okay" level of energy, and varied appetite. She reported being irritable, but denied that it was a problem. She reported limitations due to multiple chronic medical conditions, including chronic pain. She denied having any close friends outside of her family. She denied any current counseling or attending group therapy. Her depressive symptoms include depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Her nonservice-connected PTSD symptoms included nightmares, thoughts about the sexual assault, withdrawal, and paranoia. Her nonservice-connected panic disorder included variable episodes of panic attacks, from several in a day or several per week. The examiner determined that the Veteran presented with moderate occupational and social impairment due to MDD, moderate occupational and social impairment due to PTSD, and moderate occupational and social impairment due to panic disorder. A GAF score of 56 due to MDD alone was assigned. After evaluating the evidence, the Board concludes that the Veteran's symptoms of MDD do not more nearly approximate the criteria for a higher 100% rating; therefore, a rating in excess of 70% is not warranted at any time under consideration. While her MDD symptoms have at times caused major impairment in several areas, such as work, family relations, thinking, and mood, the MDD has not been characterized by symptoms that are analogous to total occupational and social impairment. In fact, no examiner or treatment provider has determined that the Veteran's symptoms equate to total occupational and social impairment. The March 2007 VA examiner determined her social adaptability and her ability to maintain employment to be severely (but not totally) impaired and assigned a GAF score of 47. The April 2009 VA examiner considered her social adaptability and ability to maintain employment to be considerably (but not totally) impaired. The December 2009 VA examiner determined that the Veteran's symptoms and GAF score of 56 demonstrated a moderate impairment of functioning. The December 2012 VA examiner determined that her symptoms only result in occupational and social impairment with reduced reliability and productivity. The Veteran stated that she was fired from her last job because she ran out of sick leave. In an August 2012 migraines VAX (conducted with respect to the Veteran's claim for a total disability rating based on individual unemployability due to service-connected disability (TDIU)), the Veteran was found to be incapacitated to work due to a combination of her pains and headaches, and not because of her MDD symptoms. The evidence shows that the Veteran maintains the house, takes care of her two children, and prepares meals. At the time of her last VA examination, she had been married for 12 to 13 years and reported a good relationship with her husband, her children, and her family. These factors weigh strongly against a finding that her symptoms produce total occupational and social impairment. The Board further notes that GAF scores of 35, 41, 45, 47, 50, 52, 55, 56, and 60 have been assigned throughout the period of the claim with respect to her service-connected MDD, reflecting major impairment to mild symptoms. The Board notes that the GAF scores on the low and high ends of 35 and 60 were assigned during a temporary hospitalization over a five day period. More significantly, GAF scores of 56 were assigned during the last two most recent VA examinations, reflecting moderate symptoms. Accordingly, the Board finds that a rating in excess of 70% for MDD is not warranted at any time during the evaluation period. The Board has also considered whether referral for extraschedular consideration is indicated. There is no objective evidence, or allegation, suggesting that the disability picture presented by the Veteran's MDD is exceptional or that schedular criteria are inadequate (the symptoms and impairment reported and shown are all encompassed by the schedular criteria for a 70% rating). See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Consequently, referral for extraschedular consideration is not warranted. Finally, the issue of entitlement to TDIU was remanded by the Board in July 2012. The Veteran was subsequently granted a TDIU rating in a December 2012 rating decision, and has not expressed disagreement with the effective date of the award. Therefore, the matter of entitlement to a TDIU rating is not currently before the Board. ORDER A rating in excess of 70% for major depressive disorder is denied. ____________________________________________ M.C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs