Citation Nr: 1611470 Decision Date: 03/22/16 Archive Date: 03/29/16 DOCKET NO. 13-15 157 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to a higher initial disability rating for anxiety disorder, rated 30 percent prior to January 13, 2009, 50 percent from January 13, 2009 through April 5, 2011, and 70 percent from April 6, 2011. 2. Entitlement to a total disability rating for compensation purposes based upon individual employability (TDIU) prior to April 6, 2011. REPRESENTATION Appellant represented by: Ralph Bratch, Attorney ATTORNEY FOR THE BOARD J. Seay, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to October 1970 and from August 2002 to December 2002. The Veteran also served in the Indiana Air National Guard. These matters come before the Board of Veterans' Appeals (Board) on appeal of a July 2010 rating decision (anxiety disorder) and a March 2013 rating decision (TDIU) by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The July 2010 rating decision granted entitlement to service connection for anxiety disorder and assigned an initial disability rating of 30 percent effective October 3, 2007 and a staged initial disability rating of 50 percent effective January 13, 2009. Subsequently, a March 2013 rating decision assigned a 70 percent disability rating effective April 6, 2011. Staged ratings have been created and the issue on appeal has been characterized as it appears on the title page of this decision. See AB v. Brown, 6 Vet. App. 35 (1993) (in an appeal in which the veteran expresses general disagreement with the assignment of a particular rating and requests an increase, the AOJ and the Board are required to construe the appeal as an appeal for the maximum benefit allowable by law or regulation). In December 2015, the Veteran's attorney submitted additional evidence to the Board including a waiver of Agency of Original Jurisdiction (AOJ) review of the evidence in accordance with 38 C.F.R. § 20.1304(c) (2015). The evidence is accepted for inclusion in the record on appeal The issue of entitlement to a TDIU prior to April 6, 2011 is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Prior to January 13, 2009, the Veteran's anxiety disorder has been productive of functional impairment comparable to no worse than 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). 2. From January 13, 2009 through April 5, 2011, the Veteran's anxiety disorder has been productive of functional impairment comparable to no worse than occupational and social impairment with reduced reliability and productivity. 3. From April 6, 2011, the Veteran's anxiety disorder has been productive of functional impairment comparable to no worse than occupational and social impairment with deficiencies in most areas, to include work, family relations, judgment, thinking, and mood. CONCLUSIONS OF LAW 1. Prior to January 13, 2009, the criteria for an initial disability rating in excess of 30 percent for anxiety disorder are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2015). 2. From January 13, 2009 through April 5, 2011, the criteria for an initial disability rating in excess of 50 percent for anxiety disorder are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2015). 3. From April 6, 2011, the criteria for an initial disability rating in excess of 70 percent for anxiety disorder are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants 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). However, 38 C.F.R. § 3.159(b)(3) (effective May 30, 2008) provides that there is no duty to provide section 5103(a) (VCAA) notice upon the Veteran's filing of a notice of disagreement as to the initial rating assignment. 73 Fed.Reg. 23353 - 23356 (April 30, 2008) (as it amends 38 C.F.R. § 3.159 to add paragraph (b)(3), effective May 30, 2008). Rather, such notice of disagreement triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as the Veteran was issued a copy of the rating decision, and a statement of the case which set forth the relevant diagnostic code rating criteria. Nevertheless, a VA letter issued in July 2012 also advised the Veteran of the regulations pertinent to the assignment of an effective date and disability rating. The duty to assist the Veteran has been satisfied in this case. The identified VA medical treatment records and Social Security Administration records have been obtained and associated with the claims file. The Veteran was provided VA medical examinations in connection with his claim for an increased disability rating for anxiety disorder. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examiners reviewed the claims file and/or took a detailed history of the Veteran's disability, performed mental status examinations of the Veteran, considered the Veteran's reported symptomatology, and provided the medical information necessary to address the rating criteria in this case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected anxiety disorder since he was last examined. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). There is no indication in the record that any additional evidence, relevant to the issue adjudicated in this decision, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Legal Criteria - Rating Disabilities Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2015). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2015). A disability rating may require re-evaluation in accordance with changes in a Veteran's condition. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). Specific Rating Criteria for rating mental disorders The Veteran's anxiety disorder is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code 9413 (2015). The VA Schedule Rating Formula for Mental Disorders reads 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, and 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; and difficulty in establishing and maintaining 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 rating - 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. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, consideration is given to all symptoms of the Veteran's anxiety disorder that affect the level of occupational and social impairment. Global Assessment of Functioning (GAF) For the purposes of considering evidence in conjunction with the rating criteria for a disability rating for anxiety disorder, the Board notes that the Global Assessment of Functioning (GAF) scale is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996). See also 38 C.F.R. §§ 4.125, 4.126, 4.130. A GAF score of 41 to 50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning. A GAF score of 51 to 60 denotes moderate symptoms (e.g. flat affect, circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF score of 61 to 70 denotes some mild symptoms (e.g. depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g. occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The provisions of 38 C.F.R. §§ 3.384 , 4.125, 4.126, 4.127, and 4.130 were updated via a final rule, effective August 4, 2014, in part to substitute references to the DSM-V for the DSM-IV. The changes are applied to applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, but not to claims certified to or pending before the Board, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit. As the Veteran's case was certified to the Board after the effective date of the final rule, the Board will refer to the DSM-V in this decision. Analysis - Anxiety Disorder The Board has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran was provided a VA examination in April 2008. The claims file was reviewed. The Veteran currently worked as a tool and die maker. Since leaving the military, he never received mental health treatment. Regarding symptoms, the Veteran reported problems with becoming angry, difficulty with being alone, but also not liking to be around a lot of people. He reported an average level of leisure pursuits and social involvement. He worked full-time as a tool and die maker. The examiner noted that, overall; the Veteran's mental health problems appeared to be of a mild severity occurring at various intervals and were present over the last year. Subjectively, the Veteran reported that he had a short temper, did not like to be alone, and stated that work was going okay. Regarding employment history, he worked as an operator and tool and die maker. From 1996 to 2006, he worked as a toolmaker until downsized. In 2007, he was a mill operator and since 2008, he worked as a tool and die maker full time. Regarding marital and family relationships, he married once and had one son. He reported a close and positive relationship with his son and four grandchildren. He stated he saw his oldest grandchild twice a month, saw his son once per month, and saw his brother once every two months. The Veteran reported that he goes out for a meal with his wife and they liked to go antiquing together. He stated that they had a friend in Illinois and visited once every three months. He reported having a couple of friends whom they see regularly. The Veteran stated that he was a member of the American Legion and attended once every two months. He stated he had a friend, B., and saw him once every two months and another friend who is a neighbor. The examiner noted that the Veteran reported good psychosocial functioning in most areas. He reported a successful career as a tool and die maker for the last 27 years. He continued to be successfully employed. The examiner noted that the Veteran reported a close and loving relationship with his wife, child, and grandchildren. He reported an average level of leisure pursuits and social involvement overall. He reported a slight tendency to prefer to be alone. Mental status examination findings revealed that the Veteran was alert, oriented, had good memory and concentration, and his insight and judgment were average. His speech was goal directed, logical and relevant. He complained of some irritability but denied impulse control problems. He did not report any obsessional activities or rituals that might interfere with routine activities. The examiner assigned a GAF score of 70. A January 6, 2009 VA evaluation noted that the Veteran had difficulty maintaining sleep and would wake up due to nightmares. He reported nightmares a few times a month and he did not like being around people. He stated that he worked as a tool and die maker. He was married and lived with his wife. He was oriented to person, place, and time. His speech was normal and his thought content was unremarkable. His memory was intact. There was no evidence of any formal thought disorder. His insight and judgment were fair. GAF scores of 64 and 66 were listed. An April 2009 VA treatment record stated that the Veteran had a tendency to blow up. He stated that he liked to be alone. A July 2009 VA treatment record noted that the Veteran was unemployed. A GAF score of 70 was assigned. He stated that he got annoyed with people when driving but did not have anger outbursts. His overall thought content seemed externally directed rather than self directed. His speech, behavior, and thought processes were within normal limits. An August 2009 VA treatment record listed a GAF score of 70. A September 2009 VA treatment record noted the Veteran's short temper and that he did not like to be around a lot of people but also did not like to be alone. A January 2010 VA treatment record noted a negative depression screen. A February 2010 VA treatment record noted that the Veteran felt "quite a bit" distant or cut off from people and reported "quite a bit" of loss of interest in activities he used to enjoy. Another February 2010 VA treatment record indicated a GAF score of 58. The Veteran had anxiety and adjustment issues. The Veteran was provided a VA examination in April 2010. The claims file was reviewed. It was noted that the Veteran was provided an initial VA examination in April 2008 and was assigned a GAF score of 70. Regarding occupational history, the Veteran reported a number of jobs over the years. He worked as a factory operator and toolmaker for 17 years. He indicated that he tended to speak his mind if he disagreed with someone's course of action. His last tool and die job ended in 2006 due to downsizing. He was unemployed for a while and then had another job for six months until he got tired of the "asshole." He was laid off from a subsequent job and returned to another job for six months. He was unemployed for a year and then worked a part-time job. Currently, he worked as a part-time truck driver. He reported that he liked it because he was essentially by himself all day and had little interaction with other people. He stated that he was only fired from two jobs. Regarding social relationships, the Veteran interacted with a couple of people. He stated that he was married and he and his wife were essentially cohabitating. The Veteran stated that as a couple, they go out to eat a couple of times per month and may watch television together in the same room in the evening. He described their relationship as "civil." He had one adopted son and described the relationship as "not real good" due to his son's "stupidity." He also stated that he had four grandchildren but did not deal well with them. He had a couple of friends and a neighbor that stops by and talks. He had one other friend whom he talks to approximately two to three times per month. His hobbies included collecting Coleman lanterns, going into the woods and cutting wood, and watching television. Most of his activities were done alone. He reported that he slept about five to six hours per night. He reported a couple of fights since he left the military but denied thoughts of wanting to hurt or kill other people and denied suicidal thoughts. On examination, his grooming and hygiene were adequate, his speech was normal in rate, rhythm, and volume. There was no evidence of psychotic symptoms, hallucinations, or delusions. He was alert and oriented to month and day of week but not the date. His immediate recall, short-term, and long-term memory were intact. His social judgment was good. Regarding depressive symptoms, he stated that he felt sad some of the time and cried more than he used to. His affect was restricted. He did not have energy to do much. He said he lost his temper four to six times per week. The examiner assigned a GAF score of 60. The examiner stated that the GAF score was at the upper range of moderate symptoms or moderate difficulty in social, occupational, and school functioning. The examiner stated that the Veteran's symptoms caused clinically significant distress and created impairments in social, occupational, and psychosocial and other important areas of functioning. His social relationships appeared the most significantly affected. He was frequently irritable and avoided other people. His enjoyment in activities diminished. The examiner stated that there was occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms but otherwise generally satisfactory functioning. The principal symptom that appeared to affect his employment was his lack of tolerance for others. He sought jobs where he was able to work alone. He had few friends and his activities were limited. During a June 2010 local hearing before a Decision Review Officer provided in connection with the issue of entitlement to service connection for claimed posttraumatic stress disorder, the Veteran testified that he had a temper and lost his temper about four to six times per week. He stated that he would verbally yell at the person. He reported an inability to control it. He reported that anger had a profound effect on his employment. He stated that he currently had a part-time job as a truck driver. He liked to spend a lot of time alone. The Veteran testified that he spent a lot of time alone in the woods or in his barn. The Veteran's wife also testified that she witnessed the Veteran's anger and temper. The Veteran's attorney noted that the records indicated a moderate severity of symptoms based upon anger, irritability, difficulty in dealing with people in stressful situations, and an inability to have meaningful relationships. A July 2010 VA treatment record noted that the Veteran would take an occasional odd job but only those where he does not work with others-while he can interact with others, he did not like working with or for others. A September 2010 VA treatment record noted that the Veteran tossed and turned at night and had episodes of anger. He stated that he immediately angered with no build up to it. A December 2010 VA treatment record noted symptoms of PTSD, anxiety, and depressive symptoms. A January 2011 VA treatment record noted that the Veteran experienced symptoms of PTSD though he seemed to present as controlled and he intellectualized most of his feelings. Another January 2011 record noted sleep interruption and the Veteran continued to display moderate symptoms. An April 6, 2011 VA treatment record shows that the Veteran reported that he was unable to work with or for someone else and had a fundamental distrust of others. He reported an increase in anxiety and had panic attacks one to two times per week. A June 2011 comprehensive psychiatric evaluation indicated symptoms of irritability, hypervigilance, and interrupted sleep. The Veteran reported anxiety, nightmares, and was increasingly isolative. He did not like crowds or busy stores. He also continued to have panic attacks several times a day to minimally several times each week. The Veteran reported his short term memory was on the decline. There were no hallucinations, his affect was appropriate, and there was no evidence of a thought disorder. His speech was normal. His GAF score was 58 which represented a moderate level of psychosocial impairment. A December 2011 record noted anxiety, sleep disturbance, intrusive thoughts and irritability experienced at a moderate level with a moderate level of impairment in psychosocial functioning. Social Security Administration records reflect that the Veteran reported a high school education and he last worked in 2010 as a truck driver. The Veteran's wife submitted a statement regarding the Veteran's functioning. She stated that the Veteran could not tolerate people for long periods of time and his sleep was restless. She said that he did not care about how he looks. She reported that the Veteran does his laundry, mows grass, does repairs, and cuts wood in the winter. She reported that he goes outside daily and drives a car. She stated that he does not go to the store very often and spends as little time as possible at the store. She reported that he spends time with others and helps his neighbor with farming and engages in a small amount of talking. He did not go to places such as church, sports events, or community center. She said that he does not have much contact with their son and barely tolerates their grandchildren. She reported that he had trouble with bosses and other employees. She said he did not handle stress as well as he used to and he was short tempered. The Veteran also provided a statement regarding his own functioning to Social Security Administration. He stated that on a typical day, he gets up, confers with his wife, and may go to town for a bite to eat. He reported that he works in his barn, mows the yard, and may visit a friend. The Veteran stated that his hobbies and interests included cutting wood, working in the barn, and being alone. He stated that he wants to be alone more and not have to deal with people any more than needed. The Veteran reported that he does not spend much time with people but if they go out to eat, most of the time it is with his wife and a few good friends. He stated that he had been diagnosed with anxiety disorder and had not had a long term, full time job for nearly five years. He reported that he found it more and more difficult to be around people for very long and wanted to be alone. The Veteran reported that he did not believe that he could go back to work in a factory or any position where he would have to deal with people for very long. The statement was signed in July 2011. A July 2011 evaluation for the purposes of Social Security Administration indicated that the Veteran's condition was reviewed from October 2010 to the present. The examining physician stated that the Veteran had marked impairment with respect to activities of daily living and social interaction and moderate impairment with respect to concentration, pace, and persistence. He also had problems with irritability, impatience with others, and panic attacks several times a day. An August 2011 letter from an employee of Work One, L.S., indicated that he worked with the Veteran for the past five years. L.S. stated that he was unable to assist the Veteran in his employment search. L.S. explained that there were very few positions in the tool and die industry. L.S. stated that the Veteran was unemployable due to unavailability of positions and his anxiety disorder which affected his ability to work in close association with others. A September 2011 VA treatment record noted anxiety, panic, dysphoria, anger outbursts, estrangement from others, interrupted sleep, nightmares and hypervigilance. It was noted that the description presented by the Veteran indicated a moderate level of impairment in psychosocial functioning. A November 2011 VA treatment record noted that the Veteran continued to experience anxiety, dysphoria, and panic attacks. The examining psychologist stated that the problems and symptoms described by the Veteran were indicative of a moderate level of impairment in psychosocial functioning and decreased sense of well-being. A January 2012 VA treatment record noted that the Veteran had frequent anxiety and depressive disorder. The examining psychologist noted that the Veteran's description indicated that he was experiencing these symptoms at a moderate level of impairment in his psychosocial functioning. A June 2012 VA treatment record shows that the Veteran liked to be alone and had trouble relating to most people. He worked around the house. The examining physician noted that he continued to experience a moderate to serious impairment in his psychosocial functioning. The Veteran was provided a VA examination in November 2012. The claims file was reviewed. The current GAF score was listed as 60. The examiner stated that the Veteran's level of occupational and social impairment was best summarized as occupational and social impairment with reduced reliability and productivity. The Veteran reported that he was still married, but his family life was described as poor. He said they do things separately and did not do much anymore. They have an adopted son whom they saw every once in a while. He reported that he saw his grandchildren a few times a month and it was difficult to be around them. It was noted that the Veteran works around his home and in the woods. He stated that he was not active in his community and that other than helping his neighbor do farm work, he had no other friendly contacts with people. He stated that he last worked in 2010 and most of his career was spent in the tool and die making/repairing field from 1997 to 2009. The examiner noted that the Social Security Administration records showed steady employment until 2006 and then gaps in the Veteran's work history. From 2009 to 2010 he was a truck driver. The Veteran reported that he last job he was fired from was in 2008 due to unwanted touching, which he denied. He stated that when he worked, he was able to do "pretty well" but sometimes had conflict with someone he viewed as an "idiot." He reported that he typically would avoid conflict by leaving the situation. The examiner noted the Veteran's VA medical treatment and that an October 2012 record indicated a GAF score of 58. On mental status examination, his appearance was appropriate, speech was appropriate, eye contact was good, and his affect was constricted. He denied depressed mood, but stated that he was not getting as much done as he would like. He denied suicidal and homicidal ideation. He reported disrupted sleep, anxiety, and panic attacks. The Veteran stated that he had a bad temper and made an effort to keep this under control. He reported that he had road rage and screamed in his car. He stated that he stayed away from people and was socially detached. His thought content was appropriate and his thought process was logical and coherent. Delusions were not present and the Veteran denied hallucinations. His abstract reasoning and memory were unimpaired. His judgment and insight were unimpaired. The examiner listed symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner opined that the Veteran's anxiety disorder appeared to render him unable to secure and maintain substantially gainful employment. The examiner's rationale noted review of the August 2011 letter from "Work One" wherein the Veteran was evaluated as unemployable due to lack of jobs in tool and die industry and trucking position and his anxiety disorder. The examiner also noted the July 2011 Social Security Administration evaluation wherein the Veteran was noted to have marked impairment with respect to activities of daily living and social interaction. The Veteran also reported little motivation for work, inflexibility in his thinking about others as "idiots", and problems tolerating and adapting to change. A February 2013 VA mental health note indicated that the Veteran reported that he had increased anxiety and dysphoria, and increased desire to be left alone. The examining psychologist noted that the Veteran had significant symptoms and problems which created a moderate-to-serious level of impairment in his psychosocial functioning, had a hugely damaging effect on ability to others, and a profoundly negative impact on employability. In a statement received by VA in December 2015, the Veteran's attorney argued that a 70 percent rating is warranted prior to April 6, 2011. Specifically, the attorney referenced a statement made by the Veteran in December 2015, in which he stated that he has a short temper, road rage, and yells, and is violent. He stated that his symptoms occurred since before 2007. He stated that since leaving the military, he always worked second or third shift or worked jobs were he was working by himself. He stated that he may have been around people, but was not working directly with them. He also stated that his relationships have been bad for years and he spent a lot of time off in the woods by himself and this had been going on since 2007. He stated that he and his wife live pretty much separate lives, but that he is the closest to her of all people. The Veteran's attorney referenced another statement from L.D., who has been married to the Veteran since 1970. The attorney noted that the Veteran's wife reported his problems with irritability and anger and strained relationships. The Veteran's attorney referenced evidence in the record, to include the April 2008 VA examination report and VA progress notes in which the Veteran reported that he does not like to be around people and has a short temper. The attorney also cited the April 2010 VA examination report wherein he stated that he only interacted with a couple of people and had problems controlling his impulses. The attorney also cited a July 2011 opinion regarding the Veteran's marked limitations in activities of daily living and marked limitations in difficulties maintaining social functioning and the opinion appeared to indicate that the limitations persisted since at least the day that the Veteran stopped working in October 2010. The attorney stated that the Veteran's symptoms more closely approximate a 70 percent rating from October 2007 and the Veteran's strained relationships, seeming "hatred" toward his grandchildren, preference for isolation, show "inability to establish and maintain effective relationships", his shaggy appearance and ragged, torn clothes were consistent with the 70 percent symptom of neglect of personal appearance and hygiene, and his irritability and anger, was consistent with the 70 percent symptom of impaired impulse control. The attorney stated that the lay statements confirm that these symptoms persisted at a level consistent with a 70 percent rating since October 2007. In a signed December 2015 statement, the Veteran stated that he had a short temper since he was in the military and can get verbally irate or violent. He stated that he has a road rage aspect and yells to himself and may yell at people. He stated that this has been going on since before 2007. The Veteran stated that he will sometimes throw things and can lose his temper very quickly. He stated that since leaving the military, he always worked second or third shift or worked jobs where he was working by himself. He may have been around people, but was not working directly with them. The Veteran stated that his relationships are bad and have been bad for years. He stated that he spent a lot of time off in the woods by himself since before 2007. He explained that he and his wife live pretty separate lives and he does not like to be around a lot of people and it has been going on for years since before 2007. He stated that they do some things together, but not a lot of things. However, he stated that he is closest to her out of all people. He stated that if he experienced stress, he goes off by himself. In a signed December 2015 statement, the Veteran's wife, L. D., stated that the Veteran is intolerant and when people do not do things that he thinks they should naturally know how to do, it frustrates and angers him. She stated that he had problems with irritability since before 2007. She stated that noise can make him angry. She reported that their relationship is strained and they pretty much live separate lives. She stated that he has very few friends and gets short with his grandchildren and has no desire to spend time with him. It was noted that he does not care much about what he is wearing and that he wears torn clothes and has to be reminded about haircuts. L. D. stated that he had difficulty with work for years. She stated that he would always tell people they were doing it wrong and he was probably getting bad reviews for his attitude around people when he worked. She stated that he has problems remembering to do things since at least 2007. She also stated that he gets depressed when he does not have something to occupy him and his mood is very down. Prior to January 13, 2009 Prior to January 13, 2009, the Board finds that the Veteran's anxiety disorder is more comparable to 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). In this respect, the April 2008 VA examiner opined that the Veteran's mental health problems were of a mild severity. During the April 2008 VA examination, the Veteran reported a close relationship with his wife, child, and grandchildren. He reported that he did have problems with his temper but denied impulse control problems. He remained employed and stated that work was going okay. In addition, the April 2008 VA examiner noted that the Veteran reported good psychosocial functioning in most areas. While the Veteran reported experiencing anxiety, anger, difficulty with being alone, but also not liking to be around a lot of people, the Board finds that the Veteran's anxiety disorder is not more comparable to occupational and social impairment with reduced reliability and productivity prior to January 13, 2009. A higher initial disability rating of 50 percent is not warranted. In addition, the symptomatology associated with the Veteran's PTSD does not more closely approximate the criteria required for a 70 percent disability rating. The evidence does not demonstrate that the Veteran's anxiety disorder is more comparable to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran may have difficulty in adapting to stressful circumstances and some impaired impulse control with respect to his anger. Concerning any depression, it has not been shown to affect his ability to function independently. Again, prior to January 13, 2009, he was employed and performed activities of daily living. While the Veteran has social impairment, he does not have an inability to establish and maintain effective relationships. Again, he remained married and reported that he had a few friends whom he visited and went out to dinner. His speech was evaluated as normal and the April 2008 VA examiner indicated that his symptoms were mild. Again, the April 2008 VA examiner noted that the Veteran reported good psychosocial functioning in most areas. In consideration of all of the manifestations of the Veteran's anxiety disorder, the Board finds that a higher disability rating of 70 percent is not warranted because the Veteran's anxiety disorder is not comparable to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Finally, the Veteran is not entitled to a 100 percent disability rating prior to January 13, 2009. The Veteran does not allege, nor does the evidence of record demonstrate total occupational and social impairment as a result of his service-connected anxiety disorder. The Veteran's anxiety disorder has not manifested in symptoms productive of functional impairment comparable to such level of impairment. The April 2008 VA examination report noted that the Veteran's symptoms were of a mild severity, the Veteran reported a close relationship with his wife, son, and grandchildren, and had friends. He was also employed. As the record does not reflect total occupational and social impairment prior to January 13, 2009, a 100 percent disability rating is not warranted. 38 C.F.R. § 4.130. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. Prior to January 13, 2009, the Veteran's GAF scores ranged from 64 to 70. Such scores represent some mild symptoms or some difficulty in social, occupational, or school functioning (e.g. occasional truancy, or theft within the household). Although GAF scores are important in evaluating mental disorders, the Board must consider all of the pertinent evidence of record in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the disability rating to be assigned; the rating is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2014). Accordingly, taking into consideration the GAF scores, the clinical findings, in addition to the VA examiner's assessment of the Veteran's symptoms as mild, the Board finds that the Veteran's anxiety disorder is more comparable to 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) prior to January 13, 2009. Therefore, prior to January 13, 2009, an initial disability rating in excess of 30 percent is not warranted. In making the above determination, the Board considered the December 2015 lay statements from the Veteran and his wife and the argument from the Veteran's attorney regarding the severity of the Veteran's symptoms since at least 2007. The Veteran's attorney argued that the Veteran is entitled to an initial 70 percent rating for the entire period on appeal. In this respect, the Board notes that the December 2015 lay statements address the Veteran's irritability and anger, strained relationships, very few friends, isolation, shaggy appearance, memory impairment, and problems with people at work. However, the Board attributes greater probative value to the objective clinical findings and the Veteran's own statements regarding his symptoms that were of record prior to January 13, 2009. Again, just that the Veteran may experience some symptoms listed in the criteria for the higher ratings of 50 percent and 70 percent, does not mandate that the Board assign a rating in excess of 30 percent. The Board assigns greater probative value to the April 2008 VA examination report wherein the VA examiner characterized the Veteran's mental health problems as mild-even when noting the Veteran's short temper and preference for being alone. In addition, the examination report stated that the Veteran continued to work full-time, describing it as "okay", and reported that he had a "close and positive relationship with his son and four grandchildren." He stated that he and his wife visits his wife's sister occasionally and he and his wife go out for a meal together and like antiquing together. During the examination, he reported having a couple of friends and a close loving relationship with wife, child, and other family members. He was able to care for his personal hygiene and activities of daily living and was dressed neatly with good grooming and hygiene. He was fully oriented with good memory and concentration and did not appear to have any memory impairment. The Veteran denied impulse control problems at that time. These reported symptoms by the Veteran at the time of the April 2008 VA examination are in contrast to the December 2015 lay statements regarding the severity of his functional impairment. Accordingly, despite the December 2015 lay statements addressing the severity of the Veteran's symptoms since 2007, the Board finds that the April 2008 VA examination report and VA medical treatment records are more probative as to his functioning and symptoms due to his anxiety disorder prior to January 13, 2009. Accordingly, an initial rating in excess of 30 percent prior to January 13, 2009, is not warranted. From January 13, 2009 through April 5, 2011 In reviewing the evidence, the Board finds that the Veteran's anxiety disorder from January 13, 2009 through April 5, 2011 is more comparable to occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130. The VA treatment records reflect symptoms of depression, short temper with impaired impulse control, social isolation, periods of unemployment, and difficulty in adapting to stressful circumstances. The April 2010 VA examination report shows that the Veteran worked part-time as a truck driver in 2010, but stopped working in October 2010. In terms of social impairment, the Veteran reported that he liked to be alone and experienced social isolation. While the Veteran has experienced depression, it does not show that it is of such severity that it affects his ability to function independently. The records reflect that the Veteran is able to mow the lawn and perform other activities of daily living to include bathing, shopping, and grooming. The Board also acknowledges the Veteran's unemployment since October 2010 and his limited social contact including a poor family life. However, the Veteran remained married and continued to engage in leisure activities such as cutting wood and working in his barn. He also stated that he helps a neighbor with farm work. During his April 2010 VA examination, he reported that he had a couple of friends and a neighbor that stopped by and talked. The VA treatment records during this time period continued to assess the Veteran's anxiety disorder symptoms and psychosocial functioning as moderate. The Board assigns great probative value to the April 2010 VA examiner's opinion that the Veteran experienced occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms but otherwise generally satisfactory functioning. The examiner's opinion is consistent with the assignment of a 50 percent disability rating for the period of January 13, 2009 through April 5, 2011. Thus, the Board finds that the Veteran's anxiety disorder is not more comparable to occupational and social impairment contemplated by the criteria for a disability rating of 70 percent during the period of January 13, 2009 through April 5, 2011. The Veteran is also not entitled to a 100 percent disability rating. The evidence of record does not demonstrate total occupational and social impairment as a result of his service-connected anxiety disorder. The Veteran's anxiety disorder has not manifested in symptoms productive of functional impairment comparable to such level of impairment. While the April 2010 VA examiner noted that the Veteran's symptoms caused significant distress and created impairments in social, occupational, and psychosocial functioning, the examiner continued to opine that the disorder manifested in occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms but otherwise generally satisfactory functioning. His speech and thoughts have been evaluated as normal with no psychotic symptoms and has behavior has been appropriate. He has consistently denied experiencing any suicidal or homicidal ideation. While he was not sure of the date on examination in April 2010, he was oriented to month and day of week and his memory was noted as being intact. As the record does not reflect total occupational and social impairment, a 100 percent disability rating is not warranted. 38 C.F.R. § 4.130. The Board considered the assigned GAF scores during the period of January 13, 2009 through April 5, 2011. The records reflect a range of GAF scores from 58 to 70 indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers) to mild symptoms 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. Taking into consideration the GAF scores, the clinical findings found on examination and multiple assessments in the VA treatment records addressing the moderate severity of the Veteran's symptoms, the Board finds that the GAF scores are consistent with the assigned staged initial disability rating of 50 percent. A staged initial rating in excess of 50 percent is not warranted from January 13, 2009 through April 5, 2011. Again, the Board considered the December 2015 lay statements, as described above, addressing the severity of his symptoms since 2007. However, the Board finds that the objective clinical findings associated with the record from January 13, 2009 to April 5, 2011 are more probative than the December 2015 statements as to the severity of his symptoms. While the Veteran and his wife may feel that his relationships were strained, his appearance poor, had poor work functioning, few friends, and impaired impulse control since at least 2007; the objective clinical findings do not reflect a level of functional impairment in excess of the assigned 50 percent rating. Indeed, as noted above, the VA treatment records repeatedly referred to the Veteran's level of impairment as moderate-consistent with the assigned 50 percent rating. In addition, the April 2010 VA examiner noted that the Veteran was currently employed as a truck driver, and while he did not like to be around other people, he was still married, ate out several times a month with his wife, and had a couple of friends. He was able to maintain his personal hygiene and other activities of daily living and his memory was intact. It was noted that he felt sad some of the time and lost his temper four to six times a week and was irritable. However, the VA examiner continued to opine that the Veteran experienced occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms but otherwise generally satisfactory functioning. Accordingly, the Board assigns greater probative value to the VA medical treatment records and VA examination report regarding the Veteran's functional impairment. The Board finds that an initial rating in excess of 50 percent from January 13, 2009 to April 5, 2011 is not warranted. From April 6, 2011 From April 6, 2011, the Board finds that the Veteran's anxiety disorder is not entitled to a higher disability rating of 100 percent. The evidence does not demonstrate total occupational and social impairment as a result of his service-connected anxiety disorder. The Veteran's anxiety disorder has not manifested in symptoms productive of functional impairment comparable to such a level of impairment. In this respect, the Board recognizes the August 2011 letter wherein it was noted that the Veteran was unemployable. In addition, the July 2011 Social Security Administration noted that the Veteran had marked impairment with respect to activities of daily living and social interaction and moderate impairment with respect to concentration, pace, and persistence. The November 2012 VA examiner listed symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. However, the November 2012 VA examiner continued to opine that the Veteran's anxiety disorder was more comparable to occupational and social impairment with reduced reliability and productivity. The Board assigns great probative value to the VA examiner's opinion as it was based on a review of the claims file, interview with the Veteran, and a mental status examination. Again, the Board acknowledges that the Veteran has been unemployed since October 2010 and has limited social contact. Nonetheless, the Veteran remains married, is able to perform activities of daily living, exhibited appropriate behavior on examination, denied any suicidal or homicidal ideations, and denied any delusions or hallucinations. The treatment records continued to note that the Veteran did not exhibit any psychotic symptoms and his speech was normal. The November 2012 VA examination findings also noted that his abstract reasoning, memory, judgment, and insight were unimpaired. He has been oriented to time and place. Finally, the Board notes that the February 2013 VA mental health note indicated significant symptoms and problems which created a moderate-to-serious level of impairment in his psychosocial functioning, have a hugely damaging effect on ability to others, and a profoundly negative impact on employability. While the Board does not doubt that the Veteran's anxiety disorder is moderate to serious, the Board finds that such an assessment is consistent with the currently assigned 70 percent disability rating. The Board finds that the evidence does not reflect that the Veteran's anxiety disorder is comparable to total occupational and social impairment. From April 6, 2011, a higher initial disability rating of 100 percent is not warranted. 38 C.F.R. § 4.130. The treatment records and November 2012 VA examination report reflect a range of GAF scores from 58 to 60 and indicate moderate symptoms or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). The assigned GAF scores are consistent with the assigned initial 70 percent disability rating from April 6, 2011. The Board considered the GAF scores with the clinical findings and the Veteran's reported symptoms and finds that the Veteran's anxiety disorder is more comparable to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood and not total occupational and social impairment. A staged initial disability rating in excess of 70 percent is not warranted from April 6, 2011. In sum, there is no identifiable period that would warrant a staged initial rating in excess of 30 percent prior to January 13, 2009, a staged initial rating in excess of 50 percent from January 13, 2009 through April 5, 2011, nor a staged initial rating in excess of 70 percent from April 6, 2011. Staged ratings, other than what are currently assigned, are not appropriate. See Fenderson, supra. In light of the above, a preponderance of the evidence is against the claim. The benefit-of-the-doubt doctrine does not apply and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Extra-schedular consideration The Board considered referral for extra-schedular consideration. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extra-schedular rating is warranted based 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) (2015). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See 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 extra-schedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Second, if the schedular rating 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 determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. With respect to the first prong in Thun, the evidence in this case does not show such an exceptional or unusual disability picture that the available schedular ratings for the service-connected anxiety disorder are inadequate. The Veteran has not contended that his anxiety disorder is exceptional or unusual, but simply requested higher ratings. As noted above, the Veteran's anxiety disorder was rated as 30 percent disabling prior to January 13, 2009, 50 percent disabling from January 13, 2009 through April 5, 2011, and 70 percent disabling from April 6, 2011. Higher schedular ratings were available during the aforementioned periods, but the Veteran's anxiety disorder did not meet the criteria for an initial rating in excess of 30 percent prior to January 13, 2009, a staged initial rating in excess of 50 percent from January 13, 2009 through April 5, 2011, or a staged initial rating in excess of 70 percent from April 6, 2011. Furthermore, the criteria in 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, refer to symptoms "such as" those specifically listed and the Board must address and consider symptoms other than those specifically listed, as well as overall level of impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, with respect to any psychiatric symptom that was not specifically listed in the criteria, the symptom is contemplated by the criteria as the criteria specifically allows for consideration of symptoms other than those specifically listed. The rating criteria are adequate and contemplate the Veteran's level of functional impairment due to anxiety disorder. Referral for extra-schedular consideration is not warranted and further inquiry is not required. See Thun, supra. ORDER For the period prior to January 13, 2009, entitlement to an initial disability rating in excess of 30 percent is denied. For the period from January 13, 2009 through April 5, 2011, entitlement to a staged initial disability rating in excess of 50 percent is denied. For the period from April 6, 2011, entitlement to a staged initial disability rating in excess of 70 percent is denied. REMAND In a March 2013 rating decision, the AOJ granted entitlement to a TDIU effective April 6, 2011, the date that the Veteran was assigned a 70 percent staged initial disability rating for service-connected anxiety disorder. The Veteran's service-connected disabilities first met the schedular criteria for entitlement to a TDIU on April 6, 2011, when he was assigned the 70 percent disability rating for anxiety disorder. 38 C.F.R. § 4.16(a) (2015). However, VA must also consider whether the Veteran is entitled to a TDIU on an extra-schedular basis prior to April 6, 2011. 38 C.F.R. § 4.16(b). The record does not reflect that the AOJ considered entitlement to a TDIU prior to the date of April 6, 2011 pursuant to 38 C.F.R. § 4.16(b). See Bernard v. Brown, 4 Vet. App. 384 (1993). The issue must be remanded to the AOJ for such consideration. Accordingly, the issue is REMANDED for the following action: Readjudicate the issue as to entitlement to a TDIU prior to April 6, 2011, to include whether referral for extra-schedular consideration is warranted for any portion of the period prior to April 6, 2011. If any benefit sought remains denied, issue a Supplemental Statement of the Case to the Veteran and his attorney. After an appropriate amount of time for response, return the appeal to the Board for review. 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). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs