Citation Nr: 1622203 Decision Date: 06/02/16 Archive Date: 06/13/16 DOCKET NO. 10-29 879 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to February 9, 2011 and 50 percent from February 9, 2011 to June 23, 2015 for anxiety. 2. Entitlement to a total disability rating on the basis of individual unemployability (TDIU) prior to June 24, 2015. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Jones, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1965 to August 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico, which granted service connection for anxiety and assigned a 10 percent disability rating, effective June 26, 2009. The rating decision also denied entitlement to a TDIU. Thereafter, in an August 2011 rating decision, the RO increased the rating for anxiety to 30 percent disabling, effective June 26, 2009. These matters were before the Board in May 2015 where they were remanded for further evidentiary development. Subsequently, in a July 2015 rating decision, the RO increased the rating for anxiety to 50 percent, effective February 9, 2011 and to 100 percent, effective June 24, 2015. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to February 9, 2011, the Veteran's anxiety was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From February 9, 2011 to June 23, 2015, the Veteran's anxiety was manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. Prior to February 9, 2011, the criteria for an initial rating in excess of 30 percent for anxiety not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9413 (2015). 2. From February 9, 2011 to June 23, 2015, the criteria for an initial rating in excess of 50 percent for anxiety not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9413 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). The anxiety claim stems from the initial grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With regard to the claim of entitlement to TDIU, notice was provided via letter dated in September 2009, which fully addressed all notice elements. See Dingess/Hartman. v. Nicholson, 19 Vet. App. 473 (2006). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Service treatment records are associated with claims file. All identified post-service treatment records have been obtained. Pursuant to the Board's May 2015 efforts to obtain records from the Social Security Administration (SSA) were made. However, in correspondence received in June 2015, the SSA reported that the requested records did not exist. As such, the Board's duty to obtain these federal records has been exhausted. The Veteran has not sufficiently identified any additional records that should be obtained prior to a Board decision. Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. The Veteran was afforded VA examinations in October 2009 and September 2010. As requested in the Board's remand directives, an additional VA examination was provided in June 2015 and a Social and Industrial Survey was provided in July 2015. The examinations are adequate for the purposes of the matters adjudicated herein, as they were based on consideration of the Veteran's pertinent medical history and described the current severity of the Veteran's disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Thereafter, the RO issued a Supplemental Statement of the Case in July 2015. In light of the foregoing, the Board finds that there has been compliance with the Board's previous remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Legal Criteria Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability is resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. In the case of an initial rating, the entire evidentiary record from the time of a veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, the Board must consider whether the disability has undergone varying and distinct levels of severity while the claim has been pending and provide staged ratings during those periods. Hart v. Mansfield, 21 Vet. App. at 509-10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran's service-connected anxiety has been rated under Diagnostic Code 9413 for unspecified anxiety disorder. Under the General Rating Formula, a 30 percent evaluation will be assigned when there is evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9413. A 50 percent rating is assigned when the evidence shows 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. Id. A 70 percent disability rating applies when occupational and social impairment reflects 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned when there is 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; and memory loss for names of close relatives, own occupation, or own name. Id. Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit explained that the frequency, severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. See 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443; see also Vazquez-Claudio, 713 F.3d at 117. Prior to February 9, 2011 Prior to February 9, 2011, the Veteran's anxiety was assigned a 30 percent disability rating. The Veteran was provided a VA mental disorders examination in October 2009. At that time, the Veteran mentioned that he had been married for 32 years to his second wife and had 3 sons with whom he had good relationships. He described an average degree of quality and social relationships. His activities and leisure pursuits consisted of caring for birds. He denied a history of suicide attempts or violence. Reported symptoms included isolation, difficulty sleeping, and restlessness. On mental examination it was noted that he Veteran was clean, his psychomotor activity was unremarkable, and speech was spontaneous. His attitude toward the examiner was cooperative, affect was appropriate, mood was anxious but good, thought process and content were unremarkable, and attention and orientation were intact. Additionally, there were no delusions or hallucinations. The Veteran understood the outcome of his behavior was determined to have average intelligence. He did not have inappropriate or obsessive/ritualistic behavior, panic attacks, or suicidal or homicidal thoughts. Remote and recent memory was normal but immediate memory was mildly impaired. It was determined that the Veteran had the ability to maintain minimum personal hygiene. It was noted that the appellant was unemployed at the time of the examination due to retirement in 2002. The examiner assigned a Global Assessment of Functioning (GAF) score of 60 and opined that the condition did not have an effect on the Veteran's occupational or social functioning. In an October 2009 statement from the Veteran's wife, she indicated that his variable personality was due to his ear condition, which caused him to become irritated and isolate himself when exposed to some noises. In September 2010, the Veteran was afforded a posttraumatic stress disorder (PTSD) examination, which revealed a diagnosis of anxiety disorder, treated with medication. It was noted that the Veteran had been married twice: in 1967 and 1977. He was still married to his second wife and had 3 sons with whom he the described his relationship as "very good." He lived with his wife and mother-in-law and reported that he had a good relationship with both. The Veteran stated that most of his time was spent at home taking care of his pets, shopping with his wife, or participating in his hobby of fixing refrigerators. He mentioned that he liked to take care of his pets, which consisted of 15 birds and 1 dog, and walk in the morning with his wife. He also visited church on Sunday and attended movies with his family. The Veteran denied a history of suicide attempts or violence and there was no evidence of psychosocial dysfunction. On physical examination, the Veteran was neatly groomed, appropriately dressed, and casually dressed. Speech was spontaneous, clear, and coherent, and attitude was cooperative, friendly, relaxed, and attentive. His affect was appropriate, mood was happy, and attention was intact. He was oriented to person, place, and time. Thought process and content were unremarkable, there were no delusions or hallucinations, and he understood the outcome of behavior. The Veteran had average intelligence and understood that he had a problem. There was no sleep impairment, inappropriate behavior, obsessive/ritualist behavior, panic attacks, or homicidal or suicidal thoughts. He had good impulse control and had the ability to maintain minimum personal hygiene. Remote, recent, and immediate memory were normal. Noted symptoms included recurrent, intrusive, and distressing thoughts and difficulty falling or staying asleep. It was reported that Veteran retried in 2003 due to being eligible by age or duration of work. The examiner assigned a GAF score of 80 and determined that the appellant's mental disorder symptoms were not severe enough to interfere with occupational and social functioning. In a subsequent VA psychiatry evaluation note dated in January 2011, the Veteran reported a history of depression and anxiety and side effects with medication to include nausea, upset stomach, and dizziness. Chronic symptoms of depression consisted of loss of energy, decreased motivation in daily chores/tasks, episodes of flashbacks and intrusive thoughts about war events, and being socially withdrawn and isolated. Episodes of anxiety, difficulty sleeping, restlessness, visual hallucinations, irritability, and verbal outbursts were also mentioned. He denied physical aggression and auditory hallucinations. Although the Veteran stated that he had passive death wishes, he denied suicidal ideas and/plans. He also stated that he attended church activities weekly. On mental status examination, the Veteran was appropriately dressed and groomed, had spontaneous vocal speech, and his mood and affect were depressed and anxious. He was coherent, relevant and logical. He denied any homicidal or suicidal thought, plans, or ideas. Delusional thoughts were not elicited. The Veteran did not have loss associations, flight of ideas, phobias, panic attacks, obsession or compulsion, or disorders of perception. He denied any visual or auditory hallucinations. He was fully oriented to time, place, and person. The Veteran's memory and concentration were preserved and he had good insight and judgment. A GAF score of 55 was assigned. Analysis After a review of the evidence, the Board finds the Veteran's anxiety most nearly approximates the current 30 percent evaluation and assignment of the next-higher 50 percent rating is not warranted at any time during this stage of the appeal. In this regard, the Veteran's anxiety has been manifested by symptoms of depression, loss of energy, decreased motivation, episodes of flashbacks and intrusive thoughts, being socially withdrawn and isolated, anxiety, difficulty sleeping, irritability, and verbal outbursts. Although the Veteran reported that he was isolated and withdrawn at times, he reported having good relationships with his wife, children, and mother-in-law. Additionally, he attended church on Sunday, participated in weekly church activities, and went to the movies with his family. The Board finds that the foregoing symptoms are contemplated by the current 30 percent rating. See 38 C.F.R. § 4.130, Diagnostic Code 9413. In finding against the 50 percent rating, the Board finds that the evidence does not suggest that the Veteran's anxiety has resulted in occupational and social impairment with reduced reliability and productivity. With regards to the Veteran's occupation, the Board observes that is unemployed. However, the evidence reveals that he retired due to his age; therefore, the unemployment status was not attributable to his service-connected psychiatric symptoms. Notably, the VA examiners determined that appellant's mental disorder symptoms were not severe enough to interfere with occupational and social functioning. The Veteran's anxiety symptoms have also had minimal effect on his ability to maintain personal relationships. The Board acknowledges the Veteran's report of passive death wishes noted in the January 2011 VA medical record. Despite the Veteran's passive report, he denied suicidal ideas and/or plans. Moreover, he has not been shown to be in persistent danger of hurting himself or others. The Board also recognizes the Veteran's report of episodes of visual hallucinations, however, on mental evaluation, he continuously denied visual hallucinations. Thus, such reports do not indicate a disability picture commensurate with the next-higher 50 percent rating when viewed in light of all the relevant evidence of record. The Board has also considered the GAF scores assigned during the appeal period. The Veteran had a GAF score as low as 55, indicative of moderate symptoms. The Board has considered the actual symptoms and resulting impairment as set forth above, and concludes that the impairment caused by these signs and symptoms more nearly approximates a 30 percent rating, again, when considering the evidence in total. In sum, the criteria for a 50 percent rating have not been shown at any time during this stage of the appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Thus, the Board determines that throughout this stage of the rating period on appeal the preponderance of the evidence is against the assignment of an initial evaluation in excess of 30 percent for the Veteran's anxiety 38 C.F.R. § 4.7. February 9, 2011 to June 23, 2015 From February 9, 2011 to June 23, 2015, he Veteran's anxiety was assigned a 50 percent disability rating. VA medical records during this stage of the appeal demonstrate continued treatment for the Veteran's psychiatric symptoms. They are discussed next. In a VA psychiatric note dated in February 2011 it was reported that the Veteran's anxiety was treated with supportive psychotherapy and medication. At the time of treatment, the Veteran reported episodes of anxiety, restlessness, irritability with verbal outbursts, flashbacks, and intrusive thoughts. He also stated that he had passive episodes of death wishes, but denied suicidal ideas and/or plans. He reported visual hallucinations indicating that he saw shadows, but denied auditory hallucinations. He also reported difficulty sleeping. He denied aggression or aggressive thoughts. A GAF score of 55 was assigned. In a subsequent psychiatric progress note dated in April 2011, the Veteran reported that he was very forgetful and lost things around the house and had episodes of excessive anxiety upon noises of helicopters. On his leisure time, he helped with his grandchildren, did light gardening, and walked 1 to 3 hours per week. He stated that his mood was calmer and that he was able to sleep better. He denied the presence of self-harm ideas, aggressive thoughts, or hallucinations. Following evaluation, a GAF score of 55 was assigned. In a subsequent psychiatric progress note dated in October 2011, the Veteran reported that his excessive anxiety had improved, now occurring only twice per week. He also stated that his concentration had approved a little. Nightmares were reported. He denied the presence of excessive daytime somnolence, self-harm ideas, aggressive thoughts, or hallucinations. A GAF score of 55 was assigned. In a psychiatric record dated in July 2011, the Veteran's wife reported that the he was anxious and that she had observed that he had become forgetful. The Veteran denied the presence of self-harm ideas, aggressive thought, or hallucinations. A GAF score of 55 was assigned. In psychiatric progress notes from January 2012 to April 2012, the Veteran reported that he continued to have episodes of anxiety. He also mentioned that he was not sleeping well. A GAF score of 60 was assigned. In a psychiatric note dated in July 2012, the Veteran reported that he suffered episodes suggestive of flashbacks, which lasted about 5 minutes. He further mentioned that loud noises caused him to experience extreme fear/panic which lasted about 2 minutes. He also reported that he had experienced some avoidance. He denied the presence of self-harm ideas, aggressive thoughts or hallucinations. A GAF score of 60 was assigned. In a record dated in February 2013, the Veteran stated that he did not celebrate much, did not feel satisfied with his life, and wished that God would take him. Although he accepted the occasional death wish, he denied suicidal ideas, the presence of self-harm ideas, aggressive thoughts, or hallucinations. A GAF score of 60 was assigned. In a mental health note dated in July 2013, it was noted that the Veteran had mood changes and sleep disturbances, but he denied suicidal or homicidal thoughts or hallucination. At the time of evaluation, there was no evidence of perceptual disturbances. In a subsequent psychiatric note, also dated in July 2013, the Veteran reported that he babysat his grandchildren, which kept him entertained, although at times it was overwhelming. His two sons were also living in his house. He reported that he locked himself in his room around 8:00-9:00p.m. Additionally, he had been more forgetful. A GAF score of 60 was assigned. In psychological consultation note dated in September 2013, it was noted that the Veteran was referred for a neuropsychological consultation due to memory problems. At that time, he stated that he forgot names of familiar people and had difficulty retaining what he read. However, he was oriented about the nature of the evaluation process. A neuropsychological assessment was conducted in October 2013. At that time, mental status evaluation revealed that the Veteran was alert and attentive and he was fully oriented in time and place. He was cooperative, reasonable, and appropriately groomed. His speech had a normal rate and rhythm; however, articulation difficulties were noted. His mood was euthymic and his affect was congruent. The Veteran reported that he occasionally heard angels whispering in his ears and saw shadows, however, he denied experiencing such symptoms during the evaluation. It was noted that his insight was fair and that he convincingly denied suicidal and homicidal ideas. The physician noted that the Veteran attended the evaluation on time and came by himself. He was oriented about the referral purpose and nature of the evaluation process, and provided informed consent. In the summary of neuropsychological findings dated in December 2013, it was noted that the Veteran stated that he forgot names of familiar people, things he had to do, and recent conversations. He also had word finding problems and misplaced objects. Likewise, he indicated that he had trouble performing activities that required several steps, such as balancing his checkbook, for which his asked his wife's help. Furthermore, he reported that he had disorientation episodes as he had difficulty finding familiar places, but he quickly reoriented himself. In terms of emotional symptoms, the Veteran reported that he felt sadder and more irritable since he returned from the military. However, he denied suicidal and homicidal ideas, but did report suicidal wishes without plan or attempts. He reported having possible auditory and visual hallucination. It was documented that collateral information was not available since the Veteran attend the session alone. With regards to findings and recommendations, the physician noted that the Veteran presented with adequate visuospatial tasks, processing speed, semantic word fluency, delayed recognition for words, stories, and figures, and below the average delayed recall for stories and words, as well as adequate set-shifting skills, all of which were not indicative of dementia. Additionally, the appellant showed below average delayed recall, which was not significantly impaired, and mildly cured delayed recall and, although he showed learning difficulties, these seemed to be related to concentration problems, which tended to be caused or exacerbated by emotional symptoms. Results revealed the presence of mild depressive symptoms. The results also showed impairment in abstract reasoning, some attention tasks, naming, phonemic word fluency, and delayed recall for figures, all of which raised concern about a possible deterioration not entirely related to emotional symptoms, particularly taking into account the presence of several AD-risk factors (i.e. age, medical conditions, family psychiatric illness, history of alcohol abuse, and neuroimaging studies). The physician reported that the Veteran had a history of prolonged benzodiazepine use, which was also likely to cause congenitive symptoms. In a mental health note dated in February 2014, the Veteran reported that he had not been taking his medication because when he took it, he could not do his activities. It was noted that the Veteran did not report psychological symptoms. A GAF score of 50-60 was assigned. In mental health records dated in April 2014, the Veteran denied any recent behavioral changes, active suicidal or homicidal thoughts, intentions or plans, or hallucinations. There was no evidence of perceptual disturbances or delusional ideas. A GAF score of 60 was assigned. In records dated from July 2014 to November 2014, the appellant adamantly denied any ideas of wanting to hurt himself or others. He denied disorganized behavior, active hallucinations or delusions, and recent mania or hypomanic episodes. There was no evidence of disruptive, aggressive, or impulsive behavior. He also denied inflated self-esteem or grandiosity ideations, decreased need for sleep, being more talkative than usual, racing thoughts, distractibility, increased goal directed activity, and excessive involvement in pleasurable activities. He also denied problems with memory, traumatic events, panic like events, feeling worried, and fear to specific situations or objects. A GAF score of 60 was assigned. In a psychiatric note dated in January 2015, the Veteran reported that there had been improvement in his depression symptoms. He mentioned that he had less anxiety and sadness, less anhedonia, and more energy. It was noted that the Veteran had moved into a new house and had been enjoying the place. He denied suicidal ideas or death wishes. A GAF score of 60 was assigned. There were no changes reported in the subsequent May 2015 psychiatric note. Analysis After a review of the evidence, the Board finds the Veteran's anxiety most nearly approximates the current 50 percent evaluation and assignment of the next-higher 70 percent rating is not warranted at any time during this stage of the appeal. In reaching this conclusion, the Veteran's anxiety has been manifested by symptoms of anxiety, restlessness, irritability with verbal outbursts, flashbacks, and intrusive thoughts, avoidance, and difficulty sleeping. Such symptoms are contemplated by the current 50 percent rating and reflective of occupational and social impairment with reduced reliability and productivity. See 38 C.F.R. § 4.130, Diagnostic Code 9413. In finding against the 70 percent rating, the Board finds that the evidence does not suggest that the Veteran's anxiety has resulted in occupational and social impairment with deficiencies in most areas. While not dispositive, the Board notes that the evidence fails to show that the Veteran suffered from frequent obsessive rituals, speech intermittent or illogic, obscure, or irrelevant. Further, the competent medical evidence does not suggest, delusions, near-continuous panic attacks, or impaired impulse control. There is no evidence of neglect of personal appearance and hygiene or impaired thought and judgment. While the appellant reported death wishes, he denied suicidal or homicidal ideations or an intent to hurt himself or others. The evidence of record also fails to demonstrate spatial disorientation. Instead, the veteran was found to be oriented to time, person and place. Notably, during this stage of the appeal, the Veteran reported that his leisure activities included spending time with his grandchildren, to include babysitting. The Board again acknowledges the Veterans of visual hallucinations noted in the February 2011 VA treatment records. However, the wight of the evidence does not indicate that this symptom was persistent in nature. In this regard, in subsequent VA treatment records, the Veteran denied hallucinations. Thus, the report of visual hallucinations alone does indicate a disability picture commensurate with the next-higher rating when viewed in light of all the relevant evidence of record. The Board has also considered the GAF scores assigned during the appeal period. GAF scores ranged from 50-60, indicative of moderate to serious symptoms. The Board notes that, while important, the GAF scores assigned in a case are not dispositive of the evaluation and must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). The Board has considered the actual symptoms and resulting impairment as set forth above, and concludes that the impairment caused by these signs and symptoms more nearly approximates a 50 percent rating. In sum, the criteria for a 70 percent rating have not been shown at any time during this stage of the appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Thus, the Board determines that throughout this stage of the rating period on appeal the preponderance of the evidence is against the assignment of an initial evaluation in excess of 50 percent for the Veteran's anxiety 38 C.F.R. § 4.7. Extra-schedular Consideration The Board has also considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). However, this case does not present such an exceptional or unusual disability picture that it would be impracticable to apply the schedular standards, and referral is unnecessary. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Rather, the manifestations of the Veteran's anxiety, to include depression, anxiety, difficulty sleeping, and nightmares, are fully considered by the rating criteria. Additionally, the Veteran's social impairment, to include having an average degree of quality and social relationships, is also contemplated by his staged ratings. Thus, referral for consideration of an extra-schedular disability rating is not necessary at this time. See Thun, 22 Vet. App. at 115-16. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, the Veteran has not asserted, nor is it reasonably raised by the record, that there is a collective impact of his service-connected disabilities. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). Therefore, a remand for referral for extraschedular consideration on a collective basis is not warranted. ORDER Entitlement to an initial rating for anxiety in excess of 30 percent prior to February 9, 2011, and 50 percent from February 9, 2011 to June 23, 2015 is denied. REMAND The Board asserts that his service-connected disabilities preclude substantially gainful employment. The Board notes that the issue of entitlement to a TDIU was remanded by the Board in May 2015. Pursuant to the Board's remand directives, Veteran was to be scheduled for a Social and Industrial Survey to ascertain the impact of his service connected disabilities on his employability. The examiner was to assess the functional impairment caused by the Veteran's service-connected disabilities on his ability to work. The examiner was also to suggest the type or types of employment in which the Veteran would be capable of engaging with his current service-connected disabilities, given his current skill set and educational background. The Veteran was provided a Social and Industrial Survey in July 2015. The examiner determined that that there was no marked limitation in the Veteran's social and occupational function, and determined that he had mild industrial and social impairment. Notwithstanding, the examiner did not provide a rationale to support his finding and did not suggest type or types of employment that the Veteran could engage in, in light of his service-connected disabilities. Stegall v. West, 11 Vet. App. 268 (1998). Thus, additional remand is required. Additionally, the Board notes that prior to February 9, 2011, the Veteran did not meet the schedular criteria for a TDIU under § 4.16(a). In this regard, the Veteran was service connected for anxiety, rated as 30 percent disabling; bilateral hearing loss, rated as 20 percent disabling; tinnitus, rated as 10 percent disabling; and residuals of injury to the great toe, left foot, rated as 10 percent disabling. His combined disability rating prior to February 9, 2011 was 60 percent. Accordingly, he did not meet the percentage threshold requirements set forth under 38 C.F.R. § 4.16(a). He asserts that he is unemployable due to his service-connected disabilities. See May 2008 Claim for a TDIU and February 2011 Statement in Support of claim. While the Veteran fails to meet the criteria for a schedular TDIU prior to February 9, 2011, he has presented evidence indicating he is unemployable due to his service-connected disabilities. As such, referral of his TDIU claim to the Director of Compensation Service for extraschedular consideration is warranted. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an opinion with an appropriate vocational expert to ascertain the impact of his service connected disabilities on his employability. The claims file, to include this remand should be reviewed by the examiner in order to become familiar with his pertinent medical history. The examiner should assess the functional impairment caused by the Veteran's service-connected disabilities on his ability to work. The examiner should give consideration to the Veteran's level of education, special training, and previous work experience, but should not consider his age or the impairment caused by his nonservice-connected disabilities. The examiner is asked to suggest the type or types of employment in which the Veteran would be capable of engaging with his current service-connected disabilities, given his current skill set and educational background. A complete rationale for all opinions expressed must be provided in the examination report. The examiner must discuss the June 2015 VA mental health examination finding that the Veteran's service-connected mental condition caused total occupational and social impairment. 2. Refer the Veteran's claim for a TDIU prior to February 9, 2011 to the Director of Compensation Service for extraschedular consideration pursuant to the provisions of 38 C.F.R. § 4.16(b). 3. Thereafter, readjudicate the Veteran's claim of entitlement to a TDIU. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ P. SORISIO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs