Citation Nr: 1606375 Decision Date: 02/19/16 Archive Date: 03/01/16 DOCKET NO. 10-40 410 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), and status post-cholecystectomy. 2. Entitlement to an initial rating in excess of 30 percent for major depressive disorder prior to May 14, 2013 and in excess of 50 percent thereafter. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran, Veteran's spouse, two sons and daughter ATTORNEY FOR THE BOARD A. VanValkenburg, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1988 to May 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from the August 2009 and May 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Board notes the August 2009 rating decision separately granted service connection for GERD, evaluated at 10 percent disabling, IBS, evaluated as noncompensable and status post-cholecystectomy, evaluated as noncompensable. The May 2010 rating decision found clear and unmistakable error, and combined GERD, IBS and status post-cholecystectomy as one disability, evaluated at 10 percent disabling. The Veteran testified at a videoconference hearing in front of the undersigned Veteran's Law Judge (VLJ) in August 2011. A transcript of the hearing is associated with the claims file. In April 2013 the Board remanded the claim to the agency of original jurisdiction (AOJ) for further development. The requested development as to the claims adjudicated below has been completed to the extent possible, and no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). During the course of the appeal in a July 2013 RO rating decision, service connection for cognitive disorder not otherwise specified (claimed as memory loss and slowed response time as residuals of an in-service stroke) was granted, evaluated as noncompensable prior to June 18, 2010 and 30 percent disabling thereafter. The record does not reflect that the Veteran filed a notice of disagreement with either the effective assigned or the initially disability evaluation assigned. It appears that the Veteran, through her representative, believes the issue of an increased rating for a cognitive disorder not otherwise specified (referred to as "residuals of a stroke") is on appeal. See written brief presentation dated October 12, 2015. However, a timely notice of disagreement with the assignment of the initial evaluation is not associated with the claims file. To the extent that the statement of the Veteran's representative may be construed as a claim for an increased rating, the matter and it is referred to the AOJ. FINDINGS OF FACT 1. The Veteran is already in receipt of the maximum scheduler evaluation for GERD, IBS and status post-cholecystectomy, and she does not have pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 2. Giving the Veteran the benefit of the doubt, throughout the entire timeframe on appeal, the Veteran's major depressive disorder is manifested by symptoms consistent with occupational and social impairment that involves a reduced reliability and productivity with such symptoms as a depressed mood, anxiety, irritability, pressured speech, insomnia, nightmares, isolation, reduced energy levels, some reduced impulse control, concentration problems, mild memory loss and disturbances of motivation and mood; neither occupational and social impairment with deficiencies in most areas nor total occupational and social impairment is shown during this period. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent for GERD, IBS and status post-cholecystectomy have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Codes 7319-7346 (2015). 2. Resolving doubt in favor of the Veteran, for the rating period prior to May 14, 2013, the criteria for an initial evaluation of 50 percent for major depressive disorder, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.114, 4.130, Diagnostic Code 9434 (2015). 3. For the entire appeal period, the criteria for an evaluation in excess of 50 percent for major depressive disorder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.114, Diagnostic Code 9434 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Assist and Notify VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.326. The Veteran has disagreed with the initial disability rating assigned for her major depressive disorder and GERD, IBS and status post-cholecystectomy, the Board notes that once an underlying claim 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). VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claims. Service treatment records, post-service treatment records, private treatments records and lay statements have been associated with the record. Additionally, the Veteran was afforded VA mental disorders and esophageal and intestinal conditions examinations in May 2013. The Board has carefully reviewed the VA examinations of record and finds that the examinations, along with the other evidence of record, are adequate for rating purposes. Thus, with respect to the Veteran's claim, there is no additional evidence which needs to be obtained. As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. Increased ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) [holding, "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"]. GERD, IBS, and status post-cholecystectomy The Veteran is currently assigned a 30 percent evaluation for GERD, IBS, and status post-cholecystectomy pursuant to 4.114 Diagnostic Code 7346-7319 (irritable colon syndrome- hiatal hernia), effective June 1, 2009. Governing regulations provide that there are diseases of the digestive system, particularly with the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding. 38 C.F.R. §§ 4.14, 4.113 (2015). Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the Diagnostic Code that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Diagnostic Code 7319 provides ratings for irritable colon syndrome (spastic colitis, mucous colitis, etc.). Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated 30 percent disabling. 38 C.F.R. § 4.114. A 30 percent evaluation is the maximum scheduler evaluation available under Diagnostic Code 7319. Under Diagnostic Code 7346, a 10 percent evaluation is warranted for hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Factual background Post service treatment records show that the Veteran received treatment at an Air Force medical facility from 2008 through 2010 for an ongoing diagnosis of IBS and esophageal reflux which included symptoms of constipation and diarrhea. The Veteran received physical therapy, in part, for constipation and complained of chronic abdominal pain. The Veteran denied any vomiting but did report some nausea at times, with no regular occurrence reported. Regarding her esophageal reflux, the Veteran complained of heartburn and reported an increase of symptoms if she consumed caffeine or carbonated beverages. The Veteran was treated with medication for her esophageal reflux and symptoms were noted to be resolved in January 2009. Private pain management clinic records from 2008 through 2009 reflect complaints of pain with bowel movement. For example, a January 27, 2009 record noted increased pelvic pain due to increased constipation symptoms as the Veteran had not taken her stool softener medication. A February 6, 2009 record noted the Veteran had a worsening upper abdominal and stomach pain after eating or drinking anything. Private urology treatment records from 2008 through 2010 reflect treatment of multiple conditions including groin pain, frequency, urgency, nocturia. The Veteran complained of needing a splint to pass a bowel movement in a November 24, 2008 record. Private colon and rectal surgery facility records show the Veteran was referred to the facility in January 2009 due to constipation and difficulty with evacuation. The Veteran initially suffered from constipation and rectal incontinence but after starting medication she had diarrhea and mild epigastric pain. Testing revealed she had poor coordination in the anorectal region and the best way to treat it was with physical therapy. The Veteran was treated by a clinical psychologist at a private pain management clinic from October 2008 through June 2009. The Veteran communicated a history of difficult bowel movements (to the point where she had to have a finger inside her vaginal canal to pass a stool), some fecal incontinence, and a notation of a "new" symptom of heartburn in November 2008. A February 6, 2009 record noted the Veteran reported stomach pain and upon inquiry reported moderate-to-severe symptoms of blood in her stool. In a February 20, 2009 record the Veteran reported increased stomach pain, diarrhea and that she had been vomiting. The Veteran was afforded a general medical examination in March 2009. The Veteran described symptoms of IBS which were present approximately 7 years. She took medication with limited benefit. On days of diarrhea she typically experienced 2-3 loose stools. She could experience bloating, gas, abdominal pain, for which a bowel movement would help alleviate symptoms. She reported symptoms of mucus in the stools, as well as symptoms of incomplete evacuation. The Veteran did not have a history of nausea, vomiting, hemorrhoids, hernia, abdominal mass or swelling, or jaundice. There was a history of diarrhea, constipation, indigestion, heartburn or regurgitation. There was no history of fecal incontinence, post-prandial symptoms after ulcer surgery, hematemesis, melena, gallbladder attacks, or abdominal pain. The Veteran was diagnosed with status-post cholecystectomy y and the problem associated with the diagnosis was gallbladder removal; IBS and GERD with acid reflux associated with the diagnosis. IBS had effects on usual daily activities with mild effects on feeding and moderate effects on toileting. In the Veteran's September 2009 notice of disagreement the Veteran described symptoms related to status post-cholecystectomy and IBS. Due to having her gallbladder removed, she had bad abdominal pains and bloating if she ate foods with fat in them. At least twice per week she went running to the bathroom within 10 to 30 minutes after eating. She had very bad gas pains and seemed to always be bloated. She could no longer eat numerous foods like onions, anything with peppermint, sweet tea or anything spicy as she would be running to the bathroom within 10 minutes of eating or drinking. Regarding IBS, weekly she had at least 2-3 days of very loose stools or diarrhea. She had no control of her sphincter muscle. She had alternating diarrhea and constipation with constant abdominal pain, gas and constant abdominal bloating. She contended that despite her last VA examination's report that she did have abdominal guarding, she did, and she had instructed the physician during her most recent VA examination not to touch her below her belly button due to pelvic pain. It affected her work because she was constantly going to the bathroom once an urge hit. She had no control over her bowels and had to wear pads some days if she had diarrhea. The Veteran was afforded a general VA examination in March 2010. The Veteran was noted to have a history of a cholecystectomy which was conducted in September of 1994. The surgery went well without complications and she had no specific residuals status post-cholecystectomy. She described symptoms of IBS which were present for approximately 8 years. She previously experienced primarily ongoing constipation for which she took medication with limited benefit. She previously experienced 1-2 days of loose stools and diarrhea per month. At the time of the examination, she experienced diarrhea/loose stools up to 4 days per week (typically after bouts of constipation). On days of diarrhea she typically experienced 3-4 loose stools. She could experience bloating, gas, abdominal pain, for which a bowel movement would help alleviate symptoms. She reported symptoms of mucus in the stools as well as symptoms of incomplete evacuation. She would occasionally take over the counter anti-diarrhea medication with limited benefit. She described that on days when she experienced diarrhea/loose stools that she had episodes of stool incontinence and leakage. She stated that on days during which she was experiencing lose stools/diarrhea she would have 2-3 pads that demonstrated bowel/stool leakage. The Veteran described symptoms that included pyrosis. Heart burn as well as regurgitation type symptoms which had been present for approximately 8 months prior to the examination. She took over the counter medications which provided some symptom relief with no specific side effects reported. She experienced breakthrough symptoms of pyrosis and/or regurgitation on a weekly basis. She denied dysphagia, blood in stool, nausea, vomiting, or hematemesis. Her weight was steady. There was no abdominal pain associated with this condition. The Veteran had no history of nausea, vomiting, hemorrhoids, hernia, abdominal mass or swelling, or jaundice. There was a history of constipation, indigestion, heartburn and regurgitation. The Veteran did not have a history of post-prandial symptoms after ulcer surgery but did have a history of fecal incontinence, as noted. There was no history of dysphagia, hematemesis, melena, pancreatitis, or gallbladder attacks. Bowel symptoms were described as diarrhea, constipation and fecal incontinence. Diarrhea and constipation were frequent. Fecal incontinence was moderate with occasional leakage, pads were required. The abdominal examination was abnormal as there was tenderness in the left and right lower quadrant. There was no mass. The Veteran was employed full time for less than one year in escort services. She had lost less than 1 week from work in the last 12 month period due to headaches and medical appointment. The Veteran was diagnosed with status-post cholecystectomy and a problem associated with the diagnosis was gallbladder removal; IBS; and GERD with acid reflux (chronic heartburn) as an associated problem. IBS had effects on usual daily activities with mild effects on feeding and moderate effects on toileting. The 2010 general VA examination addressed the Veteran's occupational history and employability. The Veteran reported she worked at an Air Force Base doing administrative work but was fired from the position in January 2010. The reason for being terminated was due to difficulties with concentration and mentally keeping up with the pace of that particular occupation/job. She was unemployed following her termination until March 2010. She was working full time in escorting duties in and out of restricted areas. She missed work due at least once per week due to headaches and medical appointments. The Veteran did experience constipation as well as loose stools with some bowel incontinence, secondary to IBS and secondary to possible residuals following rectocele surgery. Although the condition may interfere with employment to some extent in regards to the need for frequent bathroom breaks and changing of protective garments, it was not likely that the condition would likely result in complete inability to follow substantially gainful employment. In regard to status-post cholecystectomy the Veteran had demonstrated no specific functional limitation to typical occupational duties. Likewise, gastroesophageal reflux disease would not likely result in any functional limitations to typical occupational duties. The Veteran testified regarding symptoms at an August 2011 Board hearing. She reported IBS caused either uncontrollable diarrhea or horrible constipation and blockage which caused stomach pain. The occurrence of diarrhea and constipation varied. Diarrhea could occur daily for a week and she could be bloated once a week or three times per week. It all depended, and bloating occurred with constipation. Constipation could occur daily but then diarrhea could happen for 4 days that was uncontrollable. If she had diarrhea she had no control over her bowels, pads were worn daily which she changed approximately twice per day. Change of clothing occurred weekly and she brought a change of clothes with her to work. She could have diarrhea five times per day. The Veteran soiled herself primarily during the day but it sometimes occurred at night. Nervousness and food triggered her bowel movements. Her husband testified that she used the bathroom shortly after a meal. Her son testified that he did the laundry and noticed a lot of accidents on her clothing and if they were out he often had to go back to the house and bring a change of clothes for her. Her employers were aware of and were accommodating to her situation. She got up during meetings to go to the bathroom and sometimes she was late because of "accidents." The Veteran discussed GERD, or heartburn, and reported she took TUMS for the condition. It used to be a daily occurrence but she changed her diet around and it helped. The Veteran was afforded a VA IBS examination in May 2013. The Veteran complained of chronic, intermittent and alternative constipation and diarrhea with loss of stool 3 times per day. She used pads every day and changed them on average, 3 times per day due to loss of stool. Continuous medication was required for control of the Veteran's intestinal condition. The Veteran had not had surgical treatment for an intestinal condition. Signs or symptoms attributable to non-surgical and non-infectious intestinal conditions included diarrhea, alternating diarrhea and constipation and abdominal distention. Symptoms did not include anemia, nausea, or vomiting. The Veteran had episodes of bowel disturbance with abdominal distress or exacerbations or attacks of the intestinal condition. Episodes of bowel disturbance with abdominal distress occurred more or less on a constant basis. Episodes of exacerbations and/or attacks of the intestinal condition occurred 7 or more times in the prior 12 months. There was no weight loss or malnutrition, serious complications or other general health effects attributable to the intestinal conditions. The Veteran did not have benign or malignant neoplasm or metastases related to the IBS. There were no scars related to the condition. There was a normal colonoscopy in 2010. The Veteran appeared to have severe issues due to a combination of her reflux, IBS and cholecystectomy. They interfered with daytime activities and her work. The uncontrollable bowel urge appeared to be severe. The bowel movements were unpredictable and quite sudden, forcing her to have severe, abundant bowel movements without control. She wore protective garments on a daily basis. This was a social and medical issue which was quite severe. The Veteran's current conditions included her reflux disease, IBS and post-cholecystectomy. Based on a discussion with the Veteran, the irritable bowels were productive of severe symptoms, including diarrhea and alternative diarrhea and constipation and constant abdominal distress and severe bowel urge and loss. There was no evidence of colitis, malnutrition, anemia, general debility or malabsorption related to any of those conditions. The three of the Veteran's conditions interfered with everything she did. She had difficulty with food intake and was cautious with what she ate, and many times regardless, she would have sudden bowel movements that were quite embarrassing. This interfered with her daytime activities at home, work and driving. The level of severity which included her reflux disease, irritable bowels and status post-cholecystectomy was severe. The Veteran was afforded a VA esophageal examination in May 2013. The diagnosis was GERD. The Veteran took continuous over the counter antacid medication daily for heartburn. The signs or symptoms included infrequent episodes of epigastric distress, pyrosis (heartburn) reflux and sleep disturbances more than 4 times a year with duration of less than one day. There was no esophageal stricture, spasm of the esophagus or an acquired diverticulum of the esophagus. There was no impact on the Veteran's ability to work. The Veteran was afforded a VA gallbladder and pancreas conditions examination in May 2013. The diagnosis was a cholecystectomy from 1994. The cholecystectomy had left the Veteran with diarrhea and constipation which did not require continuous medication for control of the condition. The Veteran had gallbladder disease induced dyspepsia with more than 4 episodes per year. Signs and symptoms of the condition included diarrhea (3-4 times per day) and at times two days without bowel movements but it varied. There was no steatorrhea, malabsorption, severe malnutrition or weight loss indicated. VA treatment records from 2009 through 2013 reflect ongoing complaints of IBS. The Veteran often reported alternating constipation and loose stools with some mild bowel incontinence at times. She would develop abdominal bloating if she did not have a bowel movement for several days. She had to do vaginal splinting to initiate a bowel movement. When she had diarrhea it was loose and she had multiple stools with stool incontinence which required a diaper or pad. See e.g., VA treatment record dated September 25, 2009, October 22, 2009, January 26, 2010, August 13, 2010, August 19, 2011 and August 22, 2012. The Veteran reported nausea or vomiting on several occasions but predominantly denied any vomiting or nausea symptoms. See e.g., VA treatment records dated February 7, 2011, October 22, 2012, April 11, 2013 (denies nausea and/or vomiting) in contrast with July 11, 2011 (endorses a fuzzy head with headache, nausea and vomiting with diarrhea). There was no indication of any significant weight loss. It was noted the Veteran had gained 25 pounds in the prior year in a May 28, 2010 record which was in relation to her depression. The Veteran had a February 22, 2010 colonoscopy with a normal impression (no signs of inflammatory bowel disease as discussed in an August 13, 2010 record). In a February 7, 2011 record the Veteran was having diarrhea 3-4 times per day. The Veteran was informed that she would always have problems if she did not eat the right, had changes in medication or changes in her life which caused stress or anxiety. She had no abdominal pain or distention and no blood in stools. She was advised to avoid raw vegetables and fruits, spicy and greasy foods, drink plenty of fluids and eat slow. It appears medication impacted her diarrhea negatively. See e.g., February 15, 2011 (told to decrease dosage of medication to resolve diarrhea). Analysis As noted above, a 30 percent rating is maximum scheduler evaluation available under Diagnostic Code 7319. Consequently, an increased evaluation cannot be granted under that diagnostic code. In addition, the Veteran's GERD, IBS, and status post-cholecystectomy are not productive of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health as contemplated by the higher, 60 percent rating under Diagnostic Code 7346. As noted above, the treatment records reflect that her weight has increased significantly, and she has denied vomiting, hematemesis, and melena at her VA examinations. Indeed, the VA examiners specifically noted no significant weight loss or anemia and the Veteran's weight increased during the appeal period. Despite the May 2013 VA examiner determining that the Veteran's reflux disease, irritable bowels and status post-cholecystectomy was of a severe level when combined due to difficulty with food intake, embarrassing bowel movements which interrupt her activities at home and work and driving, there are no findings that indicate a severe impairment of health. As it was specifically indicated that there were no other serious complication or other general health effects attributable to the intestinal conditions in the May 2013 VA examination. Accordingly, an evaluation in excess of 30 percent is not warranted under Diagnostic Code 7346. To the extent that the Veteran claims separate ratings for her GERD, IBS, and status post-cholecystectomy, the Board again notes that coexisting diseases of the digestive system do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. See 38 C.F.R. § 4.113. As stated above, ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Board observes that evaluations in excess of 60 percent are warranted for other digestive system disabilities. However, the record does not reflect symptomatology consistent with pronounced gastrojejunal ulcer with periodic or continuous pain unrelieved by stand ulcer therapy with period vomiting, recurring melena, or hematemesis, and weight loss, or total incapacitation as contemplated by a 100 percent rating under Diagnostic Code 7306. While the Veteran has had ulcer surgery with a history of fecal incontinence, the record does not reflect a history of dysphagia, hematemesis, melena, or pancreatitis. Under Diagnostic Code 7312, cirrhosis of the liver, primary billary cirrhosis, or cirrhotic phase of sclerosing cholangitis, disabilities of 70 percent and 100 percent with the showing of certain symptomology. Likewise, a 100 percent disability evaluation is available under Diagnostic Code 7345 for chronic liver disease without cirrhosis with near constant debilitating symptoms. However, as the record does not reflect that the Veteran's disability is manifested by cirrhosis of the liver or liver disease, evaluation under these diagnostic criteria is not warranted. On the contrary, on VA examination in March 2009, her liver was noted to be normal. Under Diagnostic Code 7323, a 100 percent rating is warranted for pronounced ulcerative colitis resulting in malnutrition, anemia, and general debility or with serious complication such as liver abscess. However, such symptomatology is not shown. On the contrary, during VA examination in May 2013, the examiner specifically noted that there was no evidence of colitis, malnutrition, anemia, general debility, or malabsorption. Thus, a higher evaluation under Diagnostic Code 7323 is not warranted. Under Diagnostic Code 7330, persistent fistula of the intestine or a fistula remaining after attempt of operative closure will warranted a 100 percent rating if it is manifested by copious and frequent fecal discharge. However, the record does not reflect that the Veteran's disability is manifested by a fistula of the intestine. Moreover, while the Veteran has fecal incontinence, the record does not reflect that such is manifested by copious and frequent discharge. She was noted to have "some" incontinence in November 2008. However, the March 2009 VA examination noted that there was no history of fecal incontinence. Rather than copious and frequent, the March 2010 examination described the incontinence as moderate with occasional leakage requiring pads. In light of the foregoing, the Board concludes that the criteria for a rating in excess of 60 percent are not met under Diagnostic Code 7330. Under Diagnostic Code 7331, a 100 percent disability evaluation is warranted for active peritonitis, tuberculous. However, this diagnostic code is not applicable as the record does not reflect that the Veteran has, or has ever had, tuberculous associated with her service-connected gastrointestinal disabilities. Under Diagnostic Code 7332, a 100 percent disability rating is warranted for impairment of sphincter control of the rectum and anus with complete loss of sphincter control. However, while the Veteran reported that she had no control of her sphincter muscle on her September 2009 notice of disagreement. While treatment records show that the Veteran has had poor coordination in the anorectal region with the physical therapy being the best treatment, the Veteran's voluminous treatment records do not show that the Veteran's disability has resulted in a complete loss of sphincter control. Thus, a rating in excess of 60 percent is not warranted under Diagnostic Code 7332. Likewise, the record does not reflect the presence of a stricture of the rectum and anus requiring colostomy. Accordingly, a higher evaluation under Diagnostic Code 7333 is not warranted. The record likewise, does not reflect that the Veteran's service connected gastrointestinal disabilities are manifested by a massive postoperative ventral hernia or malignant neoplasms of the digestive system. Accordingly, higher evaluations under Diagnostic Code 7339 and Diagnostic Code 7343 are not warranted. While a 100 percent disability is warranted under Diagnostic Code 7347 for pancreatitis with frequently recurrent disabling attacks of abdominal pain with few pain free intermissions and with steatorrhea, malabsorption, diarrhea, and severe malnutrition, the record does not reflect that the Veteran's disability is manifested by pancreatitis. Moreover, while the Veteran has complaints of diarrhea, the record does not show severe malnutrition or malabsorption. Specifically, during examination in May 2013, the examiner noted that there was no steatorrhea, malabsorption, severe malnutrition, or weight loss. Based on the foregoing, the Board finds that the weight of the evidence is against a higher evaluation for the Veteran's GERD, IBS, and status post-cholecystectomy. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Major Depressive disorder The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9434. Major depressive disorder is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. Notably, the term "such as" in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F. R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The pertinent provisions of 38 C.F.R. § 4.130 concerning the rating of psychiatric disabilities read in pertinent part as follows: 30 percent: 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 50 percent: 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 establishing effective work and social relationships. 70 percent: 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. 100 Percent: 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. See 38 C.F.R. § 4.130, Diagnostic Code 9434. The use of the term "such as" in the general rating formula for mental disorders 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 symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. Global Assessment of Functioning (GAF) scores 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); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. The Board notes that an examiner's classification of the level of psychiatric impairment by a GAF score is to be considered, but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. Factual background Treatment records from an Air Force medical facility dated from 2008 through 2010 reflect the Veteran was diagnosed with a pain disorder associated with psychological and physical factors, depression with anxiety and insomnia. See e.g., October 14, 2008 (diagnosis of pain disorder), March 13, 2009 (diagnosis of depression and anxiety) and May 4, 2009 (insomnia) records. Symptoms included irritability, a compulsive episode, a reduced energy level and depressed mood. The Veteran was referred to a private physician at a pain management clinic. In 2009, the Veteran was asked about any compulsive behaviors and the Veteran reported a prolonged gambling session but had no previous episodes as the compulsion to continue gambling was new. The records reflect ongoing treatment for various physical conditions such as pelvic pain, stress incontinence, urinary incontinence, uterine prolapse second degree, rectocele and incomplete emptying of the bladder. Private urology treatment records from 2008 through 2010 reflect the Veteran had ongoing physical complaints including chronic groin and vaginal pain, frequency, urgency, and incomplete emptying. The Veteran was most bothered by nocturia. She had ongoing pelvic floor physical therapy and saw a psychologist for stress management. A February 2009 note indicated the Veteran had recently retired from the military and was not working which she felt was "adding to her anxiety." Private pain management clinic records from 2008 through 2009 reflect treatment for pelvic pain through physical therapy. In a January 25, 2008 record the Veteran was informed of the role of emotions and mood management on physical status. The Veteran reported her life was stressful and she wondering "when is this all going to end." At this time, she was to begin outpatient psychology service for management of stressors related to chronic medical and pain-related issues. The Veteran did show some improvement in pain levels in March 2008, which was thought to be from ongoing psychology services. The Veteran was treated by a clinical psychologist at a private pain management clinic from October 2008 through June 2009. The records contain an initial October 28, 2008 psychological pain assessment and ongoing individual psychotherapy. The individual psychotherapy addressed feelings of guilt over her past choice to have rectocele surgery, life stressors, intimacy issues and sexual relations. The Veteran had symptoms of sleep trouble, nightmares (related to rectocele surgery), anxiety, stress and depression. In the above mentioned, October 28, 2008 psychological pain assessment, the Veteran was diagnosed with a pain disorder associated with both psychological factors and a general medical condition. A GAF score of 72 was assigned. The Veteran reported her mood in general was bad and her husband said she was on an emotional roller coaster. Her mood depended on whether she was having a lot of pain. She had no change in appetite and did enjoy eating. As a result of pain, she was not able to get as much done in as short of a period of time as in the past. She once enjoyed running and playing sports but had not been able to enjoy those activities for seven years. She reported that for the prior year and a half she had a sleep onset delay which felt like "forever" and if she woke up after falling asleep she would be up at least half of the night. She did not nap or rest during the day but did sometimes nap or rest on weekends. Sexual interest and activity had not changed but intercourse was very painful. When pain was bad her husband could tell because she was irritable and grouchy. In response to these symptoms, her husband would suggest that she breathe or would offer to take the kids somewhere so she could have peace and quiet. The Veteran was not on antidepressants, pain medications or medications to help her sleep. Upon mental status evaluation, the Veteran was alert and oriented in all spheres. She was cooperative and answered all questions directly, logically, and sequentially. There was no indication for a formal thought disorder, delusions or hallucination. Affect was expressed over a fairly broad range, though her mood was slightly dysthymic. She appeared worried and concerned about her medical condition. There were no speech or motor anomalies observed. Intellectually, she appeared to be functioning in the average range of intelligence, with no complains of memory and concentration difficulties. Insight and judgment appeared intact. Suicidal ideation was denied. VA treatments records from 2009 through 2010 reflect ongoing diagnoses and treatment for psychiatric conditions to include bipolar disorder II and premenstrual dysphoric disorder (PMDD) with complaints of depression, irritability and sleep trouble. Symptoms predominantly included trouble sleeping, racing thoughts, impulsivity, irritability and depression. The Veteran was noted to be well-groomed predominantly throughout treatment. At the time of the Veteran's bipolar II diagnosis, in an October 13, 2009 record, the Veteran admitted to impulsivity and had gambled hundreds of dollars since being on anti-depressants. The day prior to the evaluation she had spent $500 on clothing she had never meant to buy and felt she didn't need (when typically she was frugal). At the time of her PMDD diagnosis, in a January 14, 2010 VA treatment record, the Veteran complained of severe periods with extreme irritability, abdominal cramps, heavy periods, bloating, poor sleep and binge eating. Overall, her moods had improved though she still had difficulty sleeping at night due to lots of energy and racing thoughts. She had some pressured speech and impulsivity. Even outside of her period, her mood was predominantly irritable. Throughout treatment, the Veteran had no homicidal or suicidal thoughts, delusions or hallucinations. Insight was consistently fair (at times good), memory was good, and attention was intact. Speech was at times normal but was at other times pressured, as noted. Thought content and process was predominately linear, logical, and future oriented and reality based. Insight and judgement were predominantly fair to good. At times the Veteran had an agitated psychomotor. On several occasions, the Veteran reported yelling at her family. See February 12, 2010 and March 13, 2010 VA treatment records. In a February 12, 2010 record, the Veteran reported having anger and irritability with her family (described as yelling as mentioned above). She coped by playing computer games and talking to her husband. The Veteran's reported mood ranged from "a little sad," "fine" to "good." See e.g., records dated November 6, 2009 (better but still a little depressed) June 11, 2010 (good, less sad), July 2, 2010 (a little sad) and August 31, 2010 (fine). The Veteran's assigned GAF scores ranged from 40 to 68, with scores mostly occurring around 60 in 2009 but decreasing in 2010 to 40. In a March 2009 VA general medical examination the Veteran had a normal affect, mood, comprehension of commands and judgement. Behavior was appropriate and there was no obsessive behavior. The Veteran was afforded a VA PTSD examination in March 2009. Significant military history included pelvic injuries which occurred during delivery of her youngest child. The Veteran continued to have vaginal pain, urinary incontinence which caused limitations in sexual relationships. The Veteran was treated from 2004 through 2009 for emotional conditions related to consequences of the surgery. The Veteran was not hospitalized for any mental disorder. The Veteran had symptoms over the past year and was treated with anti-depressants and other medication with no side effects. The Veteran had individual psychotherapy but it was still too early to assess for effectiveness of therapy. Depression was manifested by symptoms of lack of motivation and decreased energy. The Veteran had decreased concentration. The Veteran felt sad and had significant sleep disturbances with nightmares 20 out of 30 days. She woke up after nightmares about her surgery and was unable to get back to sleep and experienced emotional distress. Her interests had been decreased which was most likely related to the physical limitations but also part of the depression. Some guilt continued because she went against the advice of her husband and friends. The Veteran had a 30 pound weight gain. There was some psychomotor slowing. There were no suicidal thoughts or plans. Symptoms were consistent with a diagnosis of major depressive disorder. The Veteran's husband continued to be helpful and supportive. Social relationships included two close friends, her husband and her family members. Physical exercise was limited but she still went to the gym every week or two because her friend made her go. Other leisure activities were limited, except watching television. There was no history of suicide attempts, violence/assaultiveness or issues associated with alcohol/substance abuse. Upon physical examination, the Veteran was clean, neatly groomed and appropriately dressed. Psychomotor activity was unremarkable, speech was spontaneous and clear. The attitude toward examiner was cooperative, friendly, relaxed and attentive. Affect was appropriate and mood was dysphoric. Attention was intact, the Veteran was able to do serial 7's and able to spell a word forward and backward. The Veteran was oriented to person, time and place. Thought process and content were unremarkable with no delusions or hallucinations. Judgement was intact and described as understanding the outcome of her behavior. Intelligence was above average and the Veteran had insight to her condition as she understood that she had a problem. The Veteran had sleep impairment manifested by distressing nightmares which caused her to be awake and then she had difficulty getting back to sleep. This was still part of the diagnosis of major depressive disorder. Behavior was appropriate; there was no ritualistic or obsessive behavior. There were no panic attacks, homicidal or suicidal thoughts. Impulse control was good and there were no episodes of violence. There were no problems with activities of daily living. Remote, recent and immediate memory was normal. The Veteran did not meet the criteria for a PTSD diagnosis. The Veteran was diagnosed with major depressive disorder, chronic and pain disorder associated with medical and psychological factors. The Veteran's condition was persistent and history indicated that both depression and pain disorder had been persistent at the same level, though there was an unusual period of time when she was relatively symptom free in January 2009. The VA examiner indicated that the Veteran's had occupation and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks but with generally satisfactory functioning (routine behavior, self-care and conversation normal). The level of psychiatric symptoms were likely to cause some decreased in work efficiency and some intermittent periods of inability to perform occupational tasks. A GAF score of 57 was assigned. The Veteran was provided a general medical VA examination in March 2010. The psychiatric examination revealed a normal mood, affect, judgment and comprehension of commands. Behavior was appropriate and there was no obsessive behavior. The Veteran was afforded a March 2010 mental health disorders examination to address the Veteran's condition related to individual unemployability. The VA examiner noted varying diagnoses in the record. The Veteran's initial March 2009 VA examination provided a diagnosis of major depressive disorder and pain associated with medical and psychological factors with a 57 GAF score. A March 15, 2010 VA progress note indicated treatment with a diagnosis of bipolar affective disorder type II with a 40 GAF score. Further, the Veteran was treated with private psychotherapy with an initial diagnosis of a pain disorder associated with psychological and general medical factors with a 72 GAF score. See private pain management clinic psychological pain assessment date October 28, 2008, discussed above. The Veteran had been seen twice monthly since that time. The Veteran was treated with anti-depressants for her condition with individual psychotherapy. Medication caused some sedation at work. Sadness was prominent. At times she got agitated and unhappy. At other times she was happy for one day but sad the other twenty nine days of the month. When she was happy she spent money but it would not amount to a major financial loss. The Veteran reported nightmares and she could not sleep. Sleep was interrupted 3-4 times and at times she could not get back to sleep. She had irritability and yelled at children but did not hit or abuse them. Interests were limited, she napped or watched TV. Guilt was present, energy was low. She wrote lists but lost them. She gained 10 pounds in the prior year. She had some agitation but no suicidal thoughts. Symptoms were consistent with depression. The Veteran's general appearance was clean and appropriately dressed. Psychomotor activity was unremarkable. Speech was spontaneous, clear and coherent. Attitude toward the examiner was cooperative, friendly, relaxed and attentive. Affect was appropriate and mood was dysphoric. Attention was intact. She was oriented to person, place and time. Thought process and content were unremarkable. There were no delusions. She understood the outcome of her behavior and understood she had a problem (judgement, insight). There were no homicidal/suicidal thoughts or hallucinations. There was no inappropriate behavior or obsessive/ritualistic behavior. The Veteran reported panic attack symptoms once per week; however, the examiner found the symptoms did not fit all of the criteria for a DSM-IV panic attack. Impulse control was good and there were no episodes of violence. The Veteran had an ability to maintain minimum personal hygiene. There were no problems with activities of daily living. Memory was normal (remote, recent, and immediate). The diagnosis was major depressive disorder, chronic. The VA examiner also observed a pain disorder secondary to medical and psychological factors, though it was not noted to be prominent at the time of the examination. A bipolar diagnosis was used during the course of treatment and the examiner did not disagree with the diagnosis but could not substantiate it at the time of the examination, with a detailed explanation as to why. The VA examiner found the varying diagnoses noted in the record were a continuation of the same depressive disorder that she had while on active duty, though different aspects of it were noted by different therapists. It was made clear that none of the different diagnoses were new or independent conditions. A GAF score of 57 was assigned. The examiner detailed there was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to mental signs and symptoms, but with generally satisfactory functioning (routine behavior, self-care and conversation normal). The Veteran and her husband submitted statements in June 8, 2010. The Veteran reported trouble with memory as she was forgetful of appointments if she did not write them down immediately. The Veteran's husband reported she had problems with concentrating, remembering, slow thinking and responding to questions. In a June 2010 VA psychology neurocognitive evaluation consultation the Veteran was referred for diagnostic clarification by her mental health clinic VA psychiatrist to help determine the presence of PMDD. The Veteran was diagnosed with bipolar II disorder not otherwise specified. The Veteran reported symptoms of mixed episodes including a depressed mood, thoughts of death, crying daily, concentration problems, guilt and worthlessness, fatigue, appetite increase with weight gain, hyposomnia, euphoric feelings, talkativeness, increased need for sleep and increased pleasurable activities. The most recent episode had been long, approximately 6-7 weeks but it was a particularly long episode but that others were similar. These episodes occurred for 1-2 weeks approximately 3 times per year or shorter duration of 2-3 episodes twice per month. Some mood episodes did occur in concert with per menstrual cycle. Symptoms included depression, hopelessness, tension, mood lability, irritability, decreased interest in activities, difficulty concentrating, lack of energy, overeating and bodily changes including breast tenderness and bloating. The VA examiner felt the Veteran's symptoms were likely an exacerbation of depressive symptoms that occurred throughout the month. It did not appear the Veteran suffered from PMDD. She reported her mood was generally down and episodes of panic. The Veteran lived with her husband and three children. She was working and had social support from family and friends. She derived pleasure from spending time with her children. There were no thoughts of suicide or homicide. The June 2010 VA psychologist found the diagnosis of bipolar disorder not otherwise specified was most consistent with the Veteran's report. Symptoms of panic were likely secondary to the current mood symptoms. A lack of forthrightness regarding symptoms in the evaluation made it difficult to clearly identify the specific nature of the distress and possible impairment. The VA medical professional noted that there was diagnostic uncertainty due to the Veteran's response tendencies on test instruments that would have helped clarify the situation. The Veteran's responses were consistent with a significant degree of intentional exaggeration. However, it appeared the Veteran did struggle with some mood issues and the manner of responding could be considered a cry for help. A July 2010 VA mental disorders examination addressed the Veteran's memory loss. The VA examiner observed that the Veteran was diagnosed with depression, major depressive disorder, bipolar II, PMDD and that different clinicians had made different diagnoses but depression was the common factor. The Veteran was treated with medication and individual psychotherapy with poor effectiveness of therapy. The Veteran had trouble focusing and concentrating to remember things. She had a hard time recalling past events. Upon examination, the Veteran was clean and casually dressed, psychomotor activity was unremarkable, speech was spontaneous, clear and coherent, affect was appropriate and mood was good. Attention was intact and the Veteran was oriented to person, time and place. Thought process and content were unremarkable. There were no delusions. The Veteran understood the outcome of her behavior (judgement). The Veteran had sleep impairment. There was no inappropriate behavior and proverbs were interpreted appropriately. There was no obsessive or ritualistic behavior. The Veteran reported she had panic attacks described as increased heart rate, chest pain and difficulty breathing, but it was noted the symptoms did not meet the criteria for panic attacks. There were no homicidal or suicidal thoughts. Impulse control was good and there were no episodes of violence. Minimum personal hygiene was maintained. There were no problems with activities of daily living. Remote, recent and intermediate memory was normal. There was no memory deficit in clinical interview. Neuro physical testing could not confirm the presence of a cognitive disorder. Social and occupational impairment could not be addressed concerning a cognitive disorder as a diagnosis was not established. The Veteran testified during an August 2011 Board hearing regarding her symptoms. The Veteran reported her depression was due to her physical conditions of urinating and defecating on herself all the time. The Veteran testified she lost her temper and yelled for no reason, but did not hit her children. She did not think clearly. She got depressed and would go play on her computer and stay away from everyone, seclude. At work she had a separate area so she was not around a lot of people. She reported problems with short term memory which was supported by her husband and son. The Veteran's daughter testified that her mom raised her voice high over things such as dishes, and got angry. Her son testified that she would come home and say the house was dirty but not like to give much effort in it. Often the Veteran would stay in her room and sleep. VA treatment records from 2011 through 2013 reflect ongoing psychiatric treatment through therapy and medication with varying degrees of psychiatric symptoms. The Veteran discussed issues regarding her family (including her husband and children) and work issues. The Veteran had some hypomanic periods noted in May and November 2012 records. An additional PTSD diagnosis was added. In a May 8, 2011 record, the Veteran presented with symptoms of depressed mood, anxiety, irritability, low energy and racing thoughts. In an April 12, 2011 record, the Veteran presented with an improved mood, energy level and sleep; she denied panic attacks and suicide. The Veteran reported suicidal ideation for the first time in a May 2013 record. GAF scores ranged from 49-70 throughout treatment, with scores varying but in the low 60s predominantly. The Veteran was afforded a VA May 2013 neurocognitive evaluation. The Veteran reported that after a 2004 surgery she had significant difficulties typing when she had been very good at this before, was misspelling words often, and had weakness on her left side. She was generally depressed due to her health problems. She denied that medications worked very well. She endorsed having problems sleeping, stating she could go to sleep but woke up frequently due to her incontinence and nightmares. She endorsed having PTSD related to being awake during a surgery in the past. She felt she was "going downhill." She denied experiencing any recent suicidal ideations but she did have them a month prior for the first time, which scared her. She endorsed some feelings of hopelessness due to her health issues. The Veteran had been married for almost 21 years and had three children. She spent her free time isolating in her room watching TV or playing on the computer. She endorsed having one friend. She was employed full time in an administrative position. The Veteran endorsed significant difficulties with her cognition since experiencing her stroke in 2004 and she reported that she had to write things down on post-its in order to remember what she needed to do, but she attributed this to her advancing age. She was noted to be very easily distracted by outside sounds during the testing, such as people talking in the hall outside the room. She endorsed problems with language, stating that people repeated what they had said to her because she did not understand it the first time. She had been experiencing ongoing weakness on her left side, which sometimes led her to trip upstairs and fall. Multiple tests were conducted in the neurocognitive evaluation. Concentration and attention testing revealed the Veteran had poor auditory attention but relatively good working memory abilities. The Veteran had poor visual scanning skills but intact motor speed and higher level thinking abilities. Language was average. Memory testing found she was at the low end of average range for immediate verbal memory; average for immediate recognition of visual information; mildly to moderately impaired for immediate recall of complex verbal information; and borderline for delayed memory. Visuospatial/constructional testing revealed she was in the upper end of the average range for visual perception; average to above average in all areas of problem solving and executive functioning; below average in mental flexibility; and moderately impaired range on a letter fluency task but average range for category fluency. Emotional/personality factor testing revealed the Veteran was reporting significant distress with particular concerns about her physical problems. These problems had left her unhappy with little energy or enthusiasm for concentrating on important life tasks and little hope for improvement in the future. Her performance in important social roles had probably suffered as a result and her lack of success in these roles served as an additional source of stress. The Veteran had an unusual degree of concern about physical functioning and health matters and probably impairment arising from somatic symptoms. Although the Veteran did not appear to feel hopeless and her self-esteem seemed largely intact, she did manifest affective and physiological signs of depression. She admitted openly to feelings of sadness, a loss of interest in normal activities, and a loss of a sense of pleasure in doing things that she previously enjoyed. The Veteran reported experiencing some degree of anxiety and stress but the degree of worry and stress was still within what would be considered the normal range. She reported her thought process was marked by confusion, distractibility and difficulty concentrating. She may also have problems communicating clearly because of speech that may tend to be tangential or circumstantial. She described herself as rather moody and others may view her as overly sensitive. Behavioral observations and general mental status examination revealed the Veteran presented on time to her appointment and drove herself. She was alert and oriented. She ambulated independently without difficult and did not demonstrate difficulty hearing. Mood was euthymic and affect was appropriate to content, although the Veteran described herself as generally depressed. She denied recent suicidal or homicidal ideations and denied ever experiencing hallucinations or other symptoms of psychosis. Thoughts were logical and goal-directed, although she was noted to have difficulty with verbalizing her thoughts at times. Eye contact was appropriate and speech was of normal rate, volume and rhythm. There were no unusual movements or behaviors were noted. The Veteran exhibited and described difficulty paying attention and concentrating, as she was easily distracted by outside noises. Effort was consistently good. Grooming and hygiene were appropriate and judgment and insight were intact. The Veteran was diagnosed with cognitive disorder not otherwise specified. Based on the current assessment, the Veteran was exhibiting significant cognitive deficits in several areas, including attention and verbal memory. Although her cognitive difficulties could be related to her depression, it would be unusual for depression on its own to cause deficits to the extent seen in the testing results. Therefore, it was likely that the Veteran's history of stroke was at least contributing to, if not directly causing, her current cognitive deficits. The Veteran was afforded a VA mental disorders examination in May 2013. The Veteran primary diagnosis was major depressive disorder and a congenitive disorder not otherwise specified. A GAF score of 55 was assigned. The Veteran had more than one mental disorder diagnosed but it was not possible to differentiate symptoms. The symptoms of the major depressive disorder and cognitive disorder overlapped and could not be separated without resorting to speculation. The Veteran's level of occupational and social impairment was best described as reduced reliability and productivity. Symptoms that applied to the Veteran's diagnosis included a depressed mood, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events) and disturbances in motivation and mood. Symptoms such as impaired impulse control, suicidal ideation, obsessional rituals were not indicated by the examiner. It was noted that the Veteran may have reported subjective mental health symptoms but the symptoms did not rise to the level of chronicity required for ratings. The Veteran reported that since the July 2010 VA examination she had an increase in depressive symptoms. She reported suicidal thoughts for the first time two weeks prior to the examination and reported being in a "bad funk" but had not had suicide thoughts since. She described her sleep as terrible, with nightmares. She woke up at night and could not get back to sleep. Interests were "none" and when not working she laid around. She reported there was a lot she "should be doing." Energy was low and guilt was not excessive. Weight had trended up in the prior 3 years by 20 to 30 pounds. Concentration was not good. She was a lead administrator for letters and time input. Word finding was a problem. She had oral counsel about losing her temper. She got loud but not violent. Overall, she reported her depression was worse and her medications were increased a day prior to the examination to help with depressive symptoms. The symptoms indicated a continued moderate level of depression consistent with diagnosis of major depressive disorder. Since a 2004 stroke, she reported massive headaches but she had not had an evaluation for further strokes. Upon mental status examination, the Veteran was appropriately dressed and groomed. She was spontaneous in the information she presented. Her mood was euthymic and affect was appropriate to content of thought. Thought process was logical and the reached her goal idea easily. Thought content revealed no unusual materials such as delusions or hallucinations. Sensorium was clear and she was oriented to time, person, place and situation. She could do reverse spelling and serial 7 subtractions. Her judgment was not impaired. She was not a danger to herself or others. The symptomatology that was confirmed by neurophysiological testing indicated residuals of stroke including memory loss and delayed response time. Analysis The Veteran contends her major depressive disorder warrants an initial rating in excess of 30 percent prior to May 14, 2013 and a rating in excess of 50 percent thereafter. At the outset, the Board notes that, in addition to major depressive disorder, the medical evidence also reflects a current diagnosis of cognitive disorder not otherwise specified. Where it is not possible to distinguish the effects of a no service-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As above, while the May 2013 VA examiner suggested that it was possible to identify a disease or disability (separate from her service connected major depressive disorder and headaches due to residuals of a stroke) which caused reported memory loss and delayed response time symptoms; however, the examiner clearly indicated that it was not possible to differentiate what portion of the occupational and social impairment experienced by the Veteran was caused by major depressive disorder or cognitive disorder not otherwise specified. Hence, the Board has considered all of the Veteran's psychiatric symptoms in evaluating her service-connected psychiatric major depressive disorder. Turning to the matter of a higher rating, the Board has considered the VA treatment records, VA examination reports, and private treatment records as well as lay statements from the Veteran regarding the impact of her major depressive disorder on her occupational and social impairment. The Board notes that while there has been ongoing variation in the severity of the Veteran's acquired psychiatric disorder to include major depressive disorder symptoms during the appeal period, the severity of the Veteran's symptomatology has not been substantially variant for any significant period of time; therefore, "staged" ratings are not warranted. 38 C.F.R. § 4.71a; Hart, 21 Vet. App. 505. By this decision, the Board is resolving any doubt in the Veteran's favor to award an increased rating for disability due to acquired psychiatric disorder to include major depressive disorder to 50 percent over the entire appeal period. See 38 U.S.C.A. § 5107; Gilbert, supra; Mauerhan, supra. The medical evidence of record does not indicate that the Veteran's symptomatology had worsened to a level more severe than 50 percent disabling at any point during this appeal period. See 38 C.F.R. § 4.1. Symptoms which support the Veteran's 50 percent rating include, but are not limited to, occupational and social impairment with reduced reliability and productivity as due to a depressed mood, anxiety, irritability, pressured speech, insomnia, nightmares, isolation, reduced energy levels, some reduced impulse control, concentration problems, mild memory loss and disturbances of motivation and mood all resulting in reduced reliability and productivity. In arriving at the determination above the Board has considered GAF scores assigned, which reflect predominantly mild to moderate symptomatology. Throughout the appeal period, GAF scores were at the highest 72 and at the lowest 40 reflecting. However, GAF scores most consistently ranged in the high 50s to low 60s reflecting mild to moderate symptomatology. As such, the scores do not support a disability picture associated with 70 percent rating. The Board finds that a disability rating greater than 50 percent is not appropriate for any period of time on appeal because the Veteran does not have occupational and social impairment with deficiencies in most areas. The Veteran has been employed full-time for nearly the entire appeal period. The Veteran was noted to have social support from her family and friends, as noted in the June 2010 psychology neurocognitive evaluation and as reflected throughout treatment records. Though the Veteran had some impulsivity through yelling at others, shopping, and gambling, impulse control was noted to be good in VA examinations from March 2009, March 3010, July 2010 and the most recent May 2013 examiner did not indicate "impaired impulse control" as a symptom associated with the Veteran's diagnosis. The Veteran has recently had suicidal ideation, but there was no intent or plan. The Veteran's speech has not been reported as intermittently illogical, obscure, or irrelevant. Although speech was noted to be pressured at times, it was often normal with thought content and process normal. The Veteran is able to adequately communicate her thoughts. While the Veteran has depression, it is not to the extent that she is unable to function independently. The Veteran has irritability and anger issues, but there have not been periods of violent behavior. There is no evidence of spatial disorientation. The Veteran does not have neglect of personal appearance and hygiene. Accordingly, the Board concludes that the criteria for a 70 percent rating are not met. The Board is aware that the symptoms listed under the 70 percent evaluation are essentially examples of the type and degree of symptoms for that evaluation, and that the Veteran need not demonstrate those exact symptoms to warrant a 70 percent evaluation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the Board finds that the preponderance of the evidence, including the clinical findings, shows that the Veteran's major depressive disorder symptoms more nearly approximate occupational and social impairment with reduced reliability and productivity. The Board has considered lay statements from the Veteran regarding her symptoms which include sleep trouble, depression, social isolation, irritability, anger and trouble with memory and concentration. The Board finds the Veteran's testimony regarding her behavior to be both competent and credible. The Board finds the symptoms reported are contemplated by the 50 percent rating criteria. In summary, the criteria for an initial rating of 50 percent for major depressive disorder are met, prior to May 14, 2013. Throughout the entire appeal period, the criteria for a rating in excess of 50 percent for major depressive disorder are not met. Extraschedular Consideration According to VA regulations, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); see also Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director, Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected major depressive disorder and GERD, IBS and status-post cholecystectomy are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Since the available schedular evaluation adequately contemplates the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. The Board therefore has determined that referral of these disabilities for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to an initial rating in excess of 30 percent for GERD, IBS and status post-cholecystectomy, is denied. For the period prior to May 14, 2013, entitlement to an initial rating of 50 percent, for the Veteran's major depressive disorder, is granted. For the entire appeal period, entitlement to a rating in excess of 50 percent for the Veteran's major depressive disorder, is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs