Citation Nr: 1616923 Decision Date: 04/27/16 Archive Date: 05/04/16 DOCKET NO. 10-32 360 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to a rating greater than 50 percent prior to January 2, 2014 for major depressive disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Roggenkamp, Associate Counsel INTRODUCTION The Veteran had active service from April 1985 to June 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The case was remanded in December 2013 for further development. In April 2015, the Board denied a rating in excess of 50 percent prior to January 2, 2014 for major depressive disorder, and dismissed the other claims on appeal as withdrawn. The Veteran appealed his case to the U.S. Court of Appeals for Veterans Claims (Court), and in a November 2015 Order, the Court granted the parties' Joint Motion for Remand (Joint Motion), vacated the Board's April 2015 denial of an increased rating for major depressive disorder prior to January 2, 2014, and remanded the matter to the Board for development consistent with the Joint Motion. The Joint Motion specified that the dismissals due to withdrawal were not to be disturbed. Therefore, the only issue before the Board is entitlement to a rating in excess of 50 percent prior to January 2, 2014, for major depressive disorder. The Veteran testified at a hearing before a Decision Review Officer in December 2010 and at a travel board hearing in August 2012 before the undersigned. Copies of the transcripts have been associated with the Veteran's electronic claims file. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this case should take into consideration the existence of this electronic record. FINDING OF FACT The Veteran's major depressive disorder prior to January 2, 2014 was manifested by occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for a rating of 70 percent, but no higher, for major depressive disorder were met prior to January 2, 2014. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.130, Diagnostic Code 9434 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist VA's duties to notify and assist under the Veterans Claims Assistance Act of 2000 (VCAA) have been satisfied. See 38 U.S.C.A §§ 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.326(a) (2015). A July 2009 letter notified the Veteran of VA's general criteria for rating service-connected disabilities, provided examples of the types of evidence that might support entitlement to a higher rating, and also informed the Veteran of her and VA's respective responsibilities for obtaining relevant records and other evidence in support of the claim. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 97-103 (2010); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Concerning the duty to assist, the Veteran's service treatment records, VA treatment records, and private treatment records identified by her have been associated with the claims file. See 38 C.F.R. § 3.159(c). The Board notes that although the VA treatment records only go up to 2012, the Veteran indicated in her August 2012 hearing testimony before the undersigned that she was no longer being treated at VA for her psychiatric disorder. Therefore, there is no reasonable possibility that any outstanding VA treatment records dated between August 2012 and January 2014 could provide additional support for the issue on appeal, namely the evaluation of the Veteran's depressive disorder prior to January 2, 2014. Thus, efforts to obtain these records are not warranted. Cf. Golz v. Shinseki, 590 F.3d 1317, 1321, 1321 (Fed. Cir. 2010) (holding that VA is required to obtain outstanding Federal records only "if there exists a reasonable possibility that the records could help the veteran substantiate his claim for benefits."). VA examinations were performed in August 2009 and January 2014 that include consideration of the Veteran's medical history and set forth findings that enable the Board to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2015). As the issue on appeal is limited to the evaluation of the Veteran's major depressive disorder prior to January 2, 2014, further examination is not warranted. The Board remanded this claim in December 2013 for further development. The Board finds that its remand directive to provide an appropriate VA psychiatric examination has been satisfied by the January 2014 VA examination. Stegall v. West, 11 Vet. App. 268, 271 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall). Moreover, as the issue on appeal is now limited to the evaluation of the Veteran's psychiatric disorder prior to the date of the January 2014 VA examination, any error in complying with this directive is moot. See id. (holding that the rule of prejudicial error applies in determining whether the Board's remand directives have been satisfied). The Veteran testified at a hearing before the undersigned in August 2012. Under 38 C.F.R. § 3.103(c)(2) (2015), the hearing officer has the responsibility to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that the hearing officer has two duties under § 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496. Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id. at 496-97. At the hearing, the Veteran had an opportunity to provide testimony in support of her claim, facilitated by questioning from the undersigned and her representative. The Veteran did not raise any new issues at the hearing, and there is no indication that any outstanding evidence might exist that would provide additional support for the claim. See id. In this regard, the Veteran indicated that she has only received psychiatric treatment at VA, records of which are in the file up through 2012, which is past the time the Veteran discontinued psychiatric treatment, as well as several reports of VA mental health examinations dated since 2006 and earlier. These records provide ample documentation of the Veteran's depressive disorder during the pendency of this claim. Moreover, the Board undertook additional development after the hearing was conducted, including arranging for a VA examination to address the outstanding issue of the severity of her psychiatric disorder. See id. at 498-99 (finding that any deficiencies in discharging the hearing officer's duties under § 3.103(c)(2) were rendered harmless by otherwise developing the record). Accordingly, the "clarity and completeness of the hearing record [is] intact" and there is no prejudicial error concerning the hearing officer's duties under § 3.103(c)(2). See Bryant, 23 Vet. App. at 498 (holding that the rule of prejudicial error applies to the hearing officer's duties); see also Sanders, 556 U.S. at 407, 410. In light of the above, the Veteran has had a meaningful opportunity to participate effectively in the processing of this claim, and no prejudicial error has been committed in discharging VA's duties to notify and assist. See Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009); Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004); Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011); Vogan v. Shinseki, 24 Vet. App. 159, 163 (2010). Similarly, no prejudice exists with regard to the December 2010 DRO hearing, as the record was otherwise developed since that time, and there is no indication that any outstanding evidence exists that would provide additional support for the issue on appeal. II. Increased Rating for Major Depressive Disorder The Veteran contends that a rating greater than 50 is warranted for her major depressive disorder (MDD) prior to January 2, 2014. For the following reasons, the Board finds that entitlement to a 70 percent rating, but no higher, is established for this time period. Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.20 (2015). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Furthermore, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102 (2013); Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3 (2015). Staged ratings are 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. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran's entire history is to be considered when making a disability determination. 38 C.F.R. § 4.1 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Third, the Board must weigh the probative value of the proffered evidence in light of the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2014). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102 (2015). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Veteran's service-connected MDD has been evaluated as 50 percent disabling prior to January 2, 2014 under Diagnostic Code 9434, which pertains to MDD. See 38 C.F.R. § 4.130. Almost all mental health disorders, including MDD, are evaluated under the General Rating Formula for Mental Disorders (General Rating Formula), which assigns ratings based on particular symptoms and the resulting functional impairment. See 38 C.F.R. § 4.130, Diagnostic Code 9434. Under the General Rating Formula, a 50 percent disability rating requires: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating requires: 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.) A 100 percent disability rating requires: 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. The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. See id. Rather, VA must consider all symptoms of a claimant's condition that affect his or her occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (4th ed. 1994) (DSM-IV). Id. at 443. (The Board recognizes that the Veterans Benefits Administration now utilizes the DSM-5. However, this change does not apply to a claim certified for appeal to the Board on or after August 4, 2014, as is the case here, even if such claim was subsequently remanded to the AOJ. 79 Fed. Reg. 45094 (Aug. 4, 2014)). If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (2015); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (noting that the "frequency, severity, and duration" of a veteran's symptoms "play an important role" in determining the disability level). While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. Id. In evaluating psychiatric disorders, VA also considers a claimant's Global Assessment Functioning (GAF) scores, which are based on a scale set forth in the DSM-IV reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996); DSM-IV. According to DSM-IV, a score of 61-70 indicates "[s]ome 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." A score of 51-60 indicates "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." A score of 41-50 indicates "[s]erious 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 31-40 indicates "[s]ome 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)." Id. A GAF score thus may demonstrate a specific level of impairment. See Richard, 8 Vet. App. at 267 (observing that a GAF score of 50 indicates serious impairment); accord Bowling v. Principi, 15 Vet. App. 1, 14-15 (2001). While an examiner's classification of the level of psychiatric impairment reflected in the GAF score assigned can be probative evidence, such a score is by no means determinative of the rating assigned by VA in evaluating a psychiatric disorder under the rating criteria. See 38 C.F.R. §§ 4.2, 4.126 (2015). Rather, VA must take into account all of the Veteran's symptoms and resulting functional impairment as shown by the evidence of record in assigning the appropriate rating, and will not rely solely on the examiner's assessment of the level of disability at the time of examination. See 38 C.F.R. § 4.126. The issue here is whether a rating greater than 50 percent may be assigned the Veteran's MDD prior to January 2, 2014. As shown above, a 70 percent rating requires deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to the symptoms listed in the criteria corresponding to a 70 percent rating or to symptoms of equivalent severity, frequency, and duration. See 38 C.F.R. § 4.130, Diagnostic Code 9434; see also Vazquez-Claudio, 713 F.3d at 117 (holding that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration). An August 2006 VA examination report shows that the Veteran had mood instability, and that this was a change from the initial presentation of her symptoms as being predominantly depressive. The examiner noted that the Veteran now reported that she also had symptoms of elevated mood during which she engaged in excessive spending and felt extremely energetic. Her primary and dominant mood, however, was depressed. She reported that she typically stayed "low" and tended to be socially isolated. She stated that she was not always emotionally available to her children, because she tended to isolate herself in her room. She stated that she went through long periods of time when she preferred to be by herself and during which she slept excessively. She reported sleep impairment, lacking energy, having feelings of worthlessness, increased irritability, and suicidal thoughts without any intention or plan of harming herself. The examiner noted that the Veteran had not experienced full remission from her symptoms, but exhibited some capacity to adjust even when symptomatic. She stated that her symptoms occurred nearly every day. With regard to employment, the August 2006 VA examination report reflects that the Veteran worked as a teacher in a private school, and had held this job for approximately six years. She worked with only fifteen students, and stated that she was able to work at this school because her principal was supportive and allowed her "time to regroup." She noted that she rarely missed work because of her symptoms, but often needed to take a break during the day. The examiner noted that it was unlikely she could work in a more stressful situation. Her tolerance for stress was limited and she tended to take criticism in a very personal manner. On examination, the Veteran was adequately groomed. She was oriented to person, place, and time, and showed no evidence of a thought disorder, expressing herself clearly. Her thinking was logical and goal directed. Her mood was depressed. Her affect was appropriate and of normal range and intensity. She had no panic attacks. She denied hallucinations or delusions. There was no evidence of psychosis. The examiner diagnosed cyclothymic disorder, which the examiner noted was consistent with the diagnosis provided by the Veteran's treating psychiatrist, and also noted that the former diagnosis was MDD. The examiner noted that this did not represent an additional diagnosis but rather a change in assessment of the psychiatric disorder. The examiner assigned a GAF score of 55, indicating moderate symptoms. A March 2007 VA treatment record reflects that the Veteran reported that her mood swings were milder. She denied major depression, although reported periods of depression lasting a day. There was no evidence of a thought or major mood disorder. The treating psychologist assigned a GAF score of 65, denoting mild symptoms. An August 2007 VA treatment record reflects that the Veteran did not have mood swings with the medication she was taking at the time. A GAF score of 65 was assigned. A January 2008 VA treatment record reflects that the Veteran's main complaint was insomnia with consequent lack of concentration during the day and irritability. Otherwise her mood was stable. There was no evidence of a thought disorder. Her mood was euthymic and her memory intact. A GAF score of 65 was assigned. The Veteran was prescribed Ambien at this time. However, a March 2008 VA treatment record reflects that the Veteran had to stop taking the Ambien as she could not tolerate it due to significant side effects. A March 2008 VA examination report reflects that the Veteran reported stabilizing of her mood with medication, but still experienced a lot of frustration and anger, causing her to isolate, become irritable and avoid others including her children. She reported losing her passion and interest in most things, especially her job. She felt depressed and saddened by her condition. She felt emotional and cried on occasion. She had sleep impairment, sleeping for about two to three hours each night. Without psychotropic medication, she felt extremely angry and volatile, and would spend and had even more difficulty with sleep. On examination her appearance was clean and neatly groomed, her affect was flat, and her speech, thought process, and thought content unremarkable. No abnormalities were noted with regard to judgment or insight. She did not have obsessive or ritualistic behavior. She reported panic attacks, stating that once very few months she would feel anxious or nervous about something to the point where she had to leave wherever she was at the time. The examiner noted that the panic attacks were not frequent or severely intense. She denied suicidal and homicidal thoughts. Her impulse control was good and she did not have episodes of violence. Her remote memory was normal, and her recent and immediate memory was mildly impaired. In this regard, she forgot dates, appointments, and what she was supposed to do on a daily basis. She kept lists but found herself forgetting where the lists were. With regard to employment, the March 2008 VA examination report reflects that the Veteran worked as a teacher full time and had been employed in that occupation for five to ten years. She reported missing one week during the past year due to physical illness. The examiner diagnosed cyclothymia, and noted that this diagnosis was congruent with the diagnosis provided by the Veteran's treating psychiatrist. The examiner also noted that cyclothymia was a subset of major depressive disorder, for which service connection is established. The examiner assigned a GAF score of 58, which denotes moderate symptoms. With regard to the effects of the Veteran's depression on occupational and social functioning, the March 2008 VA examiner found that it resulted in deficiencies in judgement, thinking, family relations, work, mood or school. In this regard, with respect to judgment, the examiner noted that if the Veteran was depressed she felt that her choices were impaired and regretted it later, and that she could be hurtful to others. With regard to thinking, the Veteran stated that her thinking was slow and cloudy at times. With regard to family relations, the Veteran tended to stay away from her children during episodes of depression. The examiner stated that there was no effect on work. With regard to mood, the examiner stated that the Veteran's mood was very unpredictable at times. A July 2008 VA treatment record reflects that the Veteran reported that most of the time her mood was fair. She had problems with irritability and anger about three to four times per month, had mood swings three to four times per week, and felt stressed over chronic pain and other health issues. She reported taking care of two children, staying busy on a daily basis with household chores, taking twenty-minute walks three times per week, and swimming daily. She stated that a week earlier she felt overwhelmed and frustrated by all her problems and had suicidal thoughts which came and went for two days, but that she had made no plan to harm herself. She stated that these suicidal ideations had subsided and not occurred again. A December 2008 VA treatment record reflects that the Veteran was having problems with her mood, not sleeping well with intermittent insomnia, and gaining weight. She reported having memory problems of a serious nature to the point where her supervisor had to speak with her. She stated that she would forget whether she dropped off her child at school. She stated that she stopped taking Depakote because she felt it was not helping with her mood swings and had caused "some problems with her hair." A June 2009 VA treatment record reflects that the Veteran's main complaint was insomnia. She denied major mood swings. Her memory problems persisted. She reported discontinuing some psychiatric medications due to their side effects. She did not want any medicine that caused weight gain, which the psychiatrist noted would limit the psychiatric medicines that could be prescribed. The treating psychiatrist observed that there was no thought disorder, her mood was euthymic and her memory intact. A GAF score of 55 was assigned. A July 2009 VA treatment record reflects that the Veteran wished to be placed back on Depakote, the psychiatric medication she had discontinued, stating that she "can't take this anymore" and that her children and husband could not "take it anymore." She stated that she wanted to keep her marriage. She reported having mood swings and that her husband and children were suffering. The psychiatrist observed that the Veteran did not have a thought disorder. Her mood was depressed. The psychiatrist issued a new prescription for Depakote. An August 2009 VA treatment record reflects that the Veteran reported no improvement with the medication. She was going on spending sprees which made her happy but caused problems with her husband. She was not sleeping well. She denied suicidal ideation. The psychiatrist noted that she did not have a thought disorder. Her mood was depressed. The psychiatrist assigned a GAF score of 55. At the August 2009 VA examination, the Veteran reported that she occasionally had suicidal thoughts, that she cried frequently, and felt that she did not have control over anything. She did not want to be around people, including her family. Her symptoms included sleep disturbance, depressed mood, reduced energy level, concentration mildly impaired, variable appetite, occasional suicidal thoughts without plan or intent, and feelings of inappropriate guilt. She stated that these feelings were becoming more frequent and seemed to occur almost daily. In terms of how long each symptom lasted, the Veteran reported that this was variable, but that the symptoms often lasted the whole day. The examiner noted that the severity of each of these symptoms was "mild." With regard to remissions, the Veteran stated that the symptoms had not gone away at all. With regard to employment, the August 2009 VA examination report reflects that the Veteran continued to work as a teacher at a private school teaching third and fourth graders, a job she had held for eight years. She stated that her depression had "almost cost her job" that year as her boss wanted to know what was wrong concerning her work habits. With regard to social functioning, the Veteran stated that on a scale of 1 to 10, the quality of her marital and/or family relationships was an 8. She reported having one good friend with whom she was very close, as well as other acquaintances. She stated that she used to enjoy roller skating and taking her children to amusement parks, but had to stop because these activities aggravated her fibromyalgia. She stated that she mostly read, which she enjoyed. On mental status examination, the August 2009 VA examiner found that the Veteran did not have impairment of thought process or communication. She also did not have delusions or hallucinations. She did not have memory loss or impairment. She did not have obsessive or ritualistic behavior that interfered with routine activities. She did not have impaired impulse control. The Veteran reported having nine panic attacks in the past, each of which lasted for a few minutes. During these times her heart started beating fast, and she had to leave wherever she was to calm herself down. She had chest pain and rapid breathing, and felt constricted and claustrophobic. She stated that the panic attacks had not altered her functioning and had not occurred recently. She denied changing her behaviors in response to the panic attacks. The August 2009 VA examiner concluded that the Veteran's depression was mild, and that overall the depression interfered slightly and occasionally with occupational and social functioning. The examiner noted that family functioning was mildly impaired because of mild irritability. The Veteran stated that she loved being with her children but got irritated relatively quickly. With regard to anxiety, the examiner noted that it was moderate and did not interfere with employment or social functioning as it occurred in connection with a phobia of snakes. The examiner stated that the Veteran's mental disorder was manifested by signs and symptoms that were transient or mild, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. In this regard, the Veteran had reduced concentration with occasional forgetfulness, irritability, and sleep disturbance mildly reducing cognitive efficiency at times. The examiner diagnosed major depressive disorder, mild, recurrent. The examiner assigned a GAF score of 60, denoting mild symptoms. In February 2010, the Veteran underwent a mental health diagnostic study at VA, including psychiatric testing. The Beck Depression Inventory showed that severe symptoms included punishment feelings and changes in sleeping pattern. Moderate symptoms included past failure, loss of pleasure, loss of interest, loss of energy, irritability, changes in appetite, and tiredness or fatigue. Mild symptoms included sadness, pessimism, guilty feelings, self-criticalness, suicidal thoughts or wishes, crying, agitation, indecisiveness, worthlessness, and concentration difficulty. The Veteran also endorsed symptoms of posttraumatic stress disorder (PTSD). Based on the Veteran's report of PTSD symptoms, she was referred for a consultation at VA on the same day, February 2010, to evaluate those symptoms. At this consultation, the Veteran reported poor concentration, loss of interest, anger outbursts, memory problems, feeling frequently dissatisfied, weight changes, panic attacks, feeling out of control, difficulty making decisions, feelings of regret, and grieving and sense of loss. She also reported seeing people, images, animals, objects, shapes or colors that others could not see at night. She stated that she did not want to drive anymore, and that she often thought that someone was trying to step out in the road. She also reported that when she was in bed at night she constantly worried, feeling like someone was there, and would get back up to check the doors frequently. She stated that the night before she had checked the door four times. She would also go back and recheck the doors when getting ready to leave the house. With regard to flashbacks, the Veteran reported that these occurred four to six times per week, and described these as going into a hospital and seeing injured soldiers. She indicated that these flashbacks could occur when she was in traffic, and stated that she did not understand why she was seeing this when she was trying to drive. She also reported nightmares occurring every year for the past year and a half. The consulting clinician noted in the February 2010 VA treatment record that the Veteran's depression score on testing indicated a severe level of depressive symptoms within the past two weeks. The clinician concluded that the Veteran experienced significant anxiety symptoms but did not meet the criteria for a PTSD diagnosis. The clinician diagnosed depressive disorder and anxiety, and assigned a GAF score of 58. In her December 2010 hearing testimony before a DRO, the Veteran stated that she felt depressed up to five times in a given month, and that the depression lasted "quite a bit." In her August 2012 hearing testimony before the undersigned, the Veteran stated that she had experienced side effects from the psychiatric medication she was taking and thus had to stop. She stated that she would go to work "in a slump," and that her co-workers would observe her sitting at her deck and "not doing what she's supposed to do." She stated that she got frustrated and snapped a couple of times and got angry. She testified that she had to go back and apologize to some of the teachers for her behavior. In the January 2014 VA examination report, the examiner noted that symptoms applicable to the Veteran's diagnoses included difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including in a work or a work-like setting, and obsessional rituals which interfere with routine activities. The Veteran also underwent psychometric testing at the January 2014 VA examination, whose results showed that she endorsed severe symptoms. However, the examiner noted that these results were based only on self-reported data and thus were not sufficient alone for diagnostic purposes. The examiner stated that such results should be used only after being verified for accuracy by a licensed psychologist and used in conjunction with a complete clinical examination. The examiner, who conducted a clinical evaluation of the Veteran and reviewed her medical history, indicated that he believed the Veteran was greatly over-stating her mental health symptoms on these self-reported screening instruments. The January 2014 examiner diagnosed MDD and assigned a GAF score of 70, indicating mild symptoms. The examiner concluded that the Veteran's MDD caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner noted that the Veteran had been working consistently as an elementary school teacher for private religious schools since the late 1990's and that her MDD appeared generally to range from mild to moderate in severity. The examiner also concluded that there had been no clear exacerbation of the Veteran's symptoms since the March 2008 VA examination. The AOJ assigned a 70-percent rating as of January 2, 2014 based on the findings in the above VA examination. The preponderance of the evidence shows that the Veteran's psychiatric symptoms and resultant functional impairment have most nearly approximated the criteria for a 70 percent rating prior to January 2, 2014. With regard to frequency and duration of symptoms, a July 2008 VA treatment record reflects that the Veteran reported that most of the time her mood was fair, but that she had problems with irritability and anger about three to four times per month, and mood swings three to four times per week. In her December 2010 hearing testimony before a DRO, the Veteran stated that she felt depressed up to five times in a given month. At the August 2009 VA examination, by contrast, the Veteran reported that many symptoms occurred almost daily and often lasted the whole day. In general, the evidence indicates that Veteran experienced some degree of depression and other psychiatric symptoms almost daily, but that some symptoms increased in severity a few times a week or a few times a month. For example, the Veteran stated that at times her depression and irritability rose to the degree where she self-isolated by going into her room to avoid interacting with others, including her children. However, this more pronounced level of manifestation occurred less frequently. At other times, she experienced an elevated mood, during which she had a tendency to engage in excessive spending. The Veteran thus took a mood stabilizer, Depakote, to address these symptoms and moderate their intensity, although she later reported that it did not seem to help. In short, with regard to frequency and duration, the evidence shows that the Veteran reportedly experienced at least some degree of depression and other symptoms such as irritability, sleep impairment, and decreased concentration, as well as negative and painful feelings and thoughts as described in the above records nearly all the time, and that such symptoms spiked up in intensity at least a few times a week. The Board must still determine whether such symptoms were equivalent in severity to those associated with a 70-percent rating and, if so, whether they resulted in the level of occupational and social impairment contemplated by that rating. See Vazques-Claudio, 713 F.3d at 118. This assessment requires consideration not just of the Veteran's own reported symptoms, but also of how the psychiatrists and psychologists who treated or examined her evaluated the actual level of psychiatric impairment present. The Board finds that the clinical findings of the medical professionals in this regard carry more weight than the Veteran's lay statements, as the former have the appropriate training and expertise to make an informed and objective evaluation of the severity of the Veteran's psychiatric disorder. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the medical issue in question); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (the Board must assess the credibility and weight of the evidence). With regard to the severity of the Veteran's symptoms, her depression prior to January 2, 2014 can be characterized as near-continuous depression affecting the ability to function independently, appropriately, and effectively. She experienced some degree of depression for long periods of time on an almost daily basis, though she remained able to work full time and raise two children. As her husband could be away for long periods of time (the March 2008 VA examination report states that he was away eight months out of the year), often the Veteran had to take care of her children by herself. In the July 2008 VA treatment record, she reported staying busy on a daily basis with household chores, as well as taking twenty-minute walks three times per week, and swimming daily. Moreover, there may have been some interference with her work, and she has expressed irritation toward co-workers. This does not alone indicate depression at the level of severity contemplated by a 70-percent rating; however, this information coupled with other evidence in the record indicates that the Veteran's disability picture during this time period is more adequately contemplated by a 70 percent rating. The Board notes that the results of psychometric testing showed severe symptoms of depression according to the February 2010 VA treatment record and January 2014 VA examination report. These results were based on the Veteran's own reported answers rather than a clinical assessment by a medical professional; as noted by the January 2014 VA examiner, these results in and of themselves are not reliable indicators of the severity level of a psychiatric disorder, and the examiner in fact believed she was exaggerating her symptoms. However, the treating clinician noted in the February 2010 VA treatment record that test results showed severe symptoms. Finally, the Veteran's MDD produces the level of social and occupational impairment contemplated by a 70 percent rating. See Vazques-Claudio, 713 F.3d at 116-17. The March 2008 VA examiner indicated that the Veteran's MDD resulted in deficiencies in judgement, thinking, family relations, work, mood or school, in language that mirrors that of the General Rating Formula. Moreover, with regard to its effect on thinking, the March 2008 VA examiner stated that it made her thinking slow and cloudy at times. With regard to her self-reported suicidal ideation, the evidence shows that this is represented by passive, occasional thoughts with no plan or intent; however, a 70 percent rating contemplates "suicidal ideation" as a whole, without discounting passive thoughts without plan or intent. The Veteran repeatedly reported suicidal thoughts throughout the period on appeal. This symptom is equivalent in severity to those symptoms contemplated by a 70-percent rating. The Veteran's medical records also show occasional evidence of obsessional rituals prior to January 2, 2014, in particular the February 2010 VA treatment record reflecting that several times at night the Veteran would check the doors of her house to make sure they were locked, even after going to bed, and also went back to check the doors at least once when leaving the house. Additionally, the January 2014 VA examiner listed obsessional rituals which interfere with routine activities among the Veteran's symptoms. The Veteran's reported panic attacks have occurred weekly or less often, and have not generally caused deficiencies in most areas. With regard to impaired impulse control, the Veteran has reported feelings of irritability and angry outbursts, and has stated that she sometimes stayed by herself in her room to avoid interacting with others, these manifestations did not equate to periods of violence. The Veteran has also reported going on shopping sprees during periods of elevated mood, and reported flashbacks and apparent hallucinations (i.e. seeing shapes, animals or other images at night, or someone stepping out in front of her car, which others did not see) in the February 2010 VA treatment record, though no examiner or treating clinician otherwise noted these symptoms. These symptoms by themselves do not meet or approximate the criteria for a 70 percent rating; however, when taken with the evidence as a whole, the Veteran's overall disability picture is best reflected by the 70 percent rating criteria. See 38 C.F.R. § 4.130. Given a view of the evidence as a whole, the Veteran's disability picture is most closely approximated by a 70 percent disability rating. The Veteran's suicidal thoughts and feelings, coupled with her difficulty in thinking, sleep difficulty, mild obsessional rituals, panic attacks, irritability, and difficulty functioning at her job are best represented by the criteria for a 70 percent rating. The Veteran did not have any symptoms associated with a 100-percent rating, or equivalent in severity. See 38 C.F.R. § 4.130. Moreover, as she maintained full time employment throughout the period under review, was married and raising two children, and had at least one close friend and other acquaintances, the evidence shows that total occupational and social impairment were not present. Thus, the criteria for a 100-percent rating were not met or approximated. See id. With regard to staged ratings, although there were fluctuations in the severity of the Veteran's symptoms prior to January 2, 2014, as discussed above, the preponderance of the evidence shows that, even at its worst, the Veteran's MDD did not meet or approximate the criteria for a rating greater than 70 percent at any point during this time. Thus, staged ratings are not warranted for the period under review. See Hart, 21 Vet. App. at 509-10. As there is no evidence or assertion of unemployability related to the Veteran's MDD during the pendency of this appeal, the issue of entitlement to a total disability rating based on individual unemployability (TDIU) has not been raised. See 38 C.F.R. §§ 3.340, 4.16 (2015); Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Referral of the Veteran's psychiatric disorder for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008). A comparison of her symptoms and resulting functional impairment with the schedular criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). In this regard, the Veteran's symptoms of depression, sleep impairment, memory impairment, panic attacks, occasional passive suicidal ideation, anxiety, and disturbances in motivation and mood, as well as their effects on occupational and social functioning and general level of severity, as described above, are contemplated by the General Rating Formula, which takes into account both symptoms and the degree of occupational and social impairment they cause. See 38 C.F.R. § 4.130, Diagnostic Code 9434. Although a given symptom may not be specifically mentioned in the General Rating Formula, such as crying episodes, the symptoms set forth therein are not meant to constitute an exhaustive list but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan, 16 Vet. App. at 442. Thus, the fact that a given symptom is not mentioned in the rating criteria is not in itself a basis for extraschedular referral. The Board has also considered the side effects of the Veteran's medications. In this regard, she reported that some of the medications caused weight gain and that one, Depakote, might have caused some hair loss. Weight gain is not a compensable disability, and absent loss of all body hair, alopecia areata is assigned a 0 percent rating under Diagnostic Code 7831. See 38 C.F.R. § 4.119 (2015). Moreover, these symptoms did not interfere with employment or result in frequent periods of hospitalization or other related factors. See Thun, 22 Vet. App. at 114. In the Veteran's hearing testimony before the undersigned, she also stated that medications she took for her psychiatric symptoms caused her to be in a "slump" at work. While this may have been true of medication she took prior to the period under review, such as lithium, the VA treatment records show that the only reported side-effects were related to weight gain and hair loss. Thus, the Veteran's testimony is not credible evidence of a detriment in work performance due to psychiatric medications during the period under review, since it conflicts with more probative evidence in the form of the VA treatment records showing that the only reported side effects had to do with weight gain and possible hair loss. See Caluza, 7 Vet. App. at 511 (when determining whether lay evidence is satisfactory, the Board may properly consider, among other things, its consistency with other evidence submitted on behalf of the Veteran); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant); see also White v. Illinois, 502 U.S. 346, 356 (1992) (statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment). The Veteran also was prescribed Ambien in 2008 to help with sleep which produced more severe side effects, as discussed above. However, she discontinued taking this medication within a month or two after trying it a few times. Referral for extraschedular consideration is not warranted for short-lived side effects from a trial of medication. Moreover, and in the alterative, the side effects did not produce marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19. There is no indication that the symptoms and clinical findings are otherwise exceptional or unusual for the Veteran's psychiatric disorder, or are not adequately compensated by the 70 percent rating assigned prior to January 2, 2014, as discussed above. Accordingly, the first step of the inquiry is not satisfied. Thus, consideration of whether related factors are present under the second step of the inquiry is moot. See Thun, 22 Vet. App. at 118-19. Moreover, and in the alternative, there is no evidence of frequent hospitalizations for the Veteran's psychiatric disorder or marked interference with employment (the Veteran stated that she rarely or never missed days from work due to depression). Accordingly, the Board will not refer the Veteran's MDD for extraschedular consideration. Accordingly, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and entitlement to a rating greater than 70 percent prior to January 2, 2014 for MDD is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to a rating of 70 percent, but no higher, prior to January 2, 2014 for major depressive disorder is granted. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs