Citation Nr: 1754986 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 09-14 648 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent from January 27, 2006, to January 6, 2011, and from December 1, 2012, to February 11, 2013, for resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence ("uterine disorder"). 2. Entitlement to an initial disability rating in excess of 30 percent from January 27, 2006, to January 6, 2011, and from December 1, 2012, and thereafter, for bipolar disorder. REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD T. Talamantes, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1986 to February 1987, August 1994 to August 1995, February 7, 2003, to January 26, 2006, and January 7, 2011, to November 30, 2012. She also had service in the National Guard. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated October 2006 and June 2013 by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. In the October 2006 rating decision, the RO granted service connection for the uterine disorder, assigning a 0 percent disability rating and granted service connection for bipolar disorder, assigning a 10 percent disability rating. An effective date of January 27, 2006 was assigned to both issues on appeal. The RO also granted the Veteran special monthly compensation for loss of use of a creative organ based on the removal of one ovary, in accordance with 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350. In November 2012, the Board remanded the issues on appeal for VA examinations. In the June 2013 rating decision, the RO assigned a disability rating of 60 percent for the uterine disorder, with an effective date of February 12, 2013. In September 2013, the Board found that from January 27, 2006 the uterine disorder met the criteria for a 10 percent disability rating, but that a rating in excess of 60 percent had not been met from February 12, 2013. The Board also found that from January 27, 2006, bipolar disorder met the criteria for a 30 percent disability rating. Subsequently, in September 2013, the RO assigned a 10 percent disability rating for the uterine disorder and a 30 percent disability rating for bipolar disorder, assigning both claims an effective date of January 27, 2006. In February 2015, after the Veteran appealed, the United States Court of Appeals for Veteran's Claims (Court) set aside the Board's September 2013 decision and remanded the case to the Board for compliance with the terms of the Memorandum Decision. In vacating the Board's order the Court stated that VA did not attempt to secure July 2012 mental health treatment records relevant to the Veteran's bipolar disorder claim, that the Board failed to discuss the Veteran's in September 2006 contention that her urinary frequency worsened, failed to consider the relevance of prescription medication for her uterine disorder and failed to provide an adequate statement of reasons or bases for denying extraschedular consider for her uterine disorder. The Veteran did not contest the assignment of a 60 percent rating from February 12, 2013, for the uterine disorder, so the Court deemed that issue abandoned. In accordance with the Court's February 2015 Memorandum Decision, the Board remanded the appeal in October 2015. The remand directed the RO to make efforts to obtain outstanding medical treatment records and to discuss the Veteran's reporting of worsening of symptoms in September 2006 and whether extraschedular consideration was warranted with respect to her uterine disorder claim. In April 2017, the Board remanded the matters again, finding that the directives had not been substantially complied with as required. See Stegall v. West, 11 Vet. App. 268 (1998). Upon review of the record, the Board finds that the April 2017 directives have been substantially complied with and will proceed with the appeal. A detailed discussion is below. FINDINGS OF FACT 1. Throughout the entire appeal period the Veteran's uterine disorder has been more closely manifested by urinary frequency awakening to void three to four times per night. 2. Throughout the entire appeal period, the Veteran's service-connected bipolar disorder has been manifested by symptomatology more nearly approximating occupational and social impairment with reduced reliability and productivity due to symptoms such as depression, sleep impairment, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); social and occupational impairment with deficiencies in most areas is not shown. CONCLUSIONS OF LAW 1. For the rating periods on appeal, the Veteran's uterine disorder has met the criteria for a 20 percent disability rating. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.115a, 4.116, Diagnostic Codes 7613, 7614, 7615, 7619 (2017). 2. For the rating periods on appeal, the Veteran's bipolar disorder has met the criteria for a 50 percent disability rating. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9432 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist, and Compliance with Remand Directives Neither the Veteran nor his representative has raised any issues with the duty notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."). However, as mentioned above the Veteran previously argued that the duty to assist had not been met in that the RO failed to secure records relevant to her bipolar disorder claim. Thereafter, the Court agreed with the Veteran, vacating the Board's September 2013 decision. With respect to securing medical records relevant to the Veteran's bipolar disorder claim, the Board finds that the RO substantially complied with the April 2017 remand directives and that the duty to assist has been met. VA previously sent a letter to the Veteran in November 2016 and then again in May 2017 requesting that she complete and return the enclosed waiver so that they may obtain private medical records. To date the Veteran has not responded or submitted a copy of these records. With respect to the July 2012 VA treatment records, the RO attempted to obtain these as well, but a search revealed that these records do not exist. See December 2016 VA letter to the Evidence Intake Center. Lastly, the Board notes that the Veteran's representative submitted a letter in October 2017, affirming that there were no new arguments to present and no mention was made regarding the existence of any outstanding private medical records. The remand directives also required the RO to discuss the Veteran's reporting of worsening symptoms of her uterine disorder and whether extraschedular referral with respect to her uterine disorder claim is warranted. In an August 2017 supplemental statement of the case, the RO (with respect to the Veteran's uterine disorder) included in their decision a discussion of the Veteran's report of worsening symptoms in the telephone encounter note dated September 2006 and a discussion of extraschedular criteria. For the foregoing reasons, the Board finds that the RO has substantially complied with the remand directives and the duty to assist has been met. Legal Criteria Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, 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. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Uterine Disorder The Veteran contends that her uterine disorder symptomatology is more severe than contemplated by the disability rating assigned. For the periods on appeal, the Veteran's uterine disorder is currently rated as 10 percent disabling. The RO has evaluated the reproductive organ surgery residuals including urinary dysfunction under 38 C.F.R. §§ 4.115a and 4.116. Under 38 C.F.R. § 4.116, disease, injury, or adhesions of the female reproductive organs, including the uterus, fallopian tubes, and ovaries, are rated at 30 percent if there are symptoms that are not controlled by continuous treatment, at 10 percent if there are symptoms that require continuous treatment, and at 0 percent if there are symptoms that do not require continuous treatment. Removal of one ovary is rated at 100 percent for three months after the removal, and thereafter at 0 percent. 38 C.F.R. § 4.116, Diagnostic Code 7619. The RO granted the Veteran special monthly compensation for loss of use of a creative organ based on the removal of one ovary, in accordance with 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350. Under the rating schedule under 38 C.F.R. § 4.115a for urinary frequency, a 40 percent disability rating requires daytime voiding interval less than one hour, or; awakening to void five or more times per night. A 20 percent disability rating requires daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 10 percent disability rating requires daytime voiding interval between two and three hours, or, awakening to void two times per night. Under the rating schedule under 38 C.F.R. § 4.115a for urinary incontinence or stress incontinence, a 60 percent disability rating requires the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. A disability rating of 40 percent requires the wearing of absorbent materials, which must be changed 2 to 4 times per day. A disability rating of 20 percent requires the wearing of absorbent materials, which must be changed less than 2 times per day. Bipolar Disorder The Veteran contends that her bipolar disorder symptomatology is more severe than contemplated by the disability rating assigned. The Veteran's bipolar disorder is currently rated as 30 percent disabling. Psychiatric disabilities, such as bipolar disorder, are evaluated under the General Rating Formula for Mental Disorders (pertinent portions listed below). See 38 C.F.R. § 4.130, Diagnostic Code 9432. Under the General Rating Formula for Mental Disorders, a 100 percent disability rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Id. A 70 percent disability rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or inability to establish and maintain effective relationships. Id. A 50 percent disability rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 30 percent disability rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupation 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, and mild memory loss (such as forgetting names, directions, recent events). Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. The Board notes that the DSM-5 has now been officially released and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. The Board notes, however, because most, if not all of the relevant evidence was obtained during the time period that the DSM-IV was in effect, the Board will still consider this information as relevant to this appeal. Furthermore, there is no indication that the Veteran's diagnosis would be different under the DSM-5. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). A GAF score between 41 and 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job); a GAF score between 51 and 60 is indicative of 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 coworkers); a GAF between 61 and 70 is indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships; a GAF between 71 to 80 is indicative that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; the analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation, but are not meant to be exhaustive. Id. Further, the United States Court of Appeals for the Federal Circuit has acknowledged the "symptom-driven nature" of the General Rating Formula and that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013). The Federal Circuit has explained that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Id. at 117. Factual Background and Analysis Uterine Disorder By way of an Informal Hearing Presentation dated August 2013, the Veteran initially argued for a disability rating of 10 percent to be assigned for the appeal period prior to February 2013. As stated above, a 10 percent disability rating was assigned in a September 2013 rating decision. Thereafter, by way of an Appellant's Brief submitted March 2017, the Veteran contends that a disability rating of 20 percent is warranted for voiding dysfunction. For the reasons explained below, the Board finds that a disability rating of 20 percent, but no higher is warranted for the entire timeframe on appeal. Medical treatment records indicate that the Veteran underwent surgery while in service. She underwent partial oophorectomy November 2003 and myomectomy in November 2004. A June 2003 service treatment record indicates complaint and treatment of uterine disorder. She reported very heavy periods, using 15 pads on her heaviest day. A pelvic ultra sound revealed large fibroids and bilateral ovarian cysts. The Veteran was diagnosed with dysfunctional uterine bleeding/fibroid uterus. Service treatment records dated February 2005 to December 2005 indicate complaints of and treatment for frequent urination and urinary incontinence. A service treatment note dated January 20, 2006, shows that the Veteran was being worked up for an incontinence/urinary tract recommendation for further studies. The Veteran reported that she continued to experience pain daily. However, the pain described was not attributed to a particular medical issue, as she was also being treated for joint dysfunction and patellofemoral pain syndrome during that visit. She was released with work duty limitations. In April 2006, the Veteran underwent a VA examination. Her reported history described surgical resection of a fibroid and removal of the right ovary and fallopian tube. She reported a one year history of urine leakage related to laughing, coughing, sneezing, carrying things, and climbing stairs. She stated that she urinated four to five times during the day and one to two times at night. She reported feeling as if there is incomplete emptying of the bladder. She described having irregular periods, cramps with periods, and abdominal cramps outside of her periods. She stated that she had pain in the left iliac fossa. Upon examination the examiner noted that there was tenderness, but no masses were felt in the left iliac fossa. Left iliac pain found to be residuals of fibroid resection, removal of right ovary and fallopian tube. The examiner noted that there was no hesitancy, flow was good, and urge continence was present. The examiner noted that the Veteran did have some post void dribbling, but no burning. The examiner also noted that she had been treated for urge incontinence and was performing Kegel exercise at the advice of a physical therapist to treat it. The urologist stated that she may require a sling operation for the urge incontinence. The Veteran was diagnosed with stress urinary incontinence and occasional urge incontinence and resection of the fibroid of the uterus, removal of right ovary and fallopian tube and residuals from left iliac pain. A VA medicine telephone contact note dated September 2006 indicates that the Veteran was prescribed pyridium 200 mg TID x 2 days. A VA nursing telephone care note also dated September 2006 states the Veteran reported that her symptoms of frequency and discomfort were getting worse. During the appeal period, upon review of the evidence, the Board finds all reasonable doubt in the Veteran's favor and finds that a 20 percent rating, but no higher, is warranted for the Veteran's uterine disorder. Specifically, the evidence demonstrates that the Veteran has a uterine disorder that started in service, which caused her to undergo surgeries. She has been diagnosed with dysfunctional uterine bleeding/fibroid uterus, and treated for frequent urination and urinary incontinence. A service treatment record dated 7 days before she was discharged, indicates that she was being prepared to be seen for further studies related to her uterine disorder. Additionally during the appeal period, the Veteran had episodes of urine leakage, urination up to five times a day and up to two times at night, the sensation of an incomplete emptying of the bladder, post void dribbling, irregular periods, abdominal cramps outside of her periods, and tenderness and pain in her left iliac fossa. She was also prescribed medication that she was to take three times a day for two days. Based the totality of the disability picture presented, the Board finds that the Veteran's symptoms more closely approximate to urinary frequency awakening to void three to four times per night throughout the appeal period. The Board acknowledges that the Veteran reported worsening of symptoms in September 2006. Subsequently, the Veteran had a VA examination in February 2013 to address the worsening of symptoms and the results of that examination fall outside of the appeal period before us today (as discussed in the Introduction section above, the Veteran did not contest the 60 percent rating from February 12, 2013, for her uterine disorder). The Board notes that during the appeal periods, the evidence shows varying patterns of voiding dysfunction-including instances of voiding less than three times per night. However, looking at the disability picture as a whole the Board will view the evidence in a light most favorable to the Veteran, and acknowledges the totality of her symptoms most closely approximate those associated with a 20 percent rating. In reviewing the criteria for a 40 percent disability rating and determining whether an evaluation in excess of 20 percent is warranted, the Board finds that the evidence does not establish that during the appeal period that the Veteran's uterine disorder manifested in daytime voiding interval less than one hour, or; awakening to void five or more times per night. With respect to voiding dysfunction, the evidence does not establish that during the appeal period that the Veteran's uterine disorder required the wearing of absorbent materials. The Board has considered whether staged ratings are appropriate for the Veteran's uterine disorder during anytime during the appeal period; however, the Board finds that her symptomatology has most nearly approximated symptoms such as those exemplified by the 20 percent disability criteria throughout the appeal period. Thus, staged ratings during any time during the appeal period are not warranted. In sum, a 20 percent rating, but no higher, is warranted for the entire period on appeal period. As the preponderance of the evidence is against the claim for a disability rating in excess of 20 percent, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As stated above, the Court in February 2015 vacated a previous Board decision and remanded, in part, because the Board failed to provide adequate reasons or bases for declining extraschedular referral with respect to the Veteran's uterine disorder. Therefore, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. 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). According to the regulation, an extraschedular disability 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) (2017). 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 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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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 service-connected uterine disorder are inadequate. A comparison between the level of severity and symptomatology of the Veteran's uterine disorder with the established criteria shows that the rating criteria reasonably describe her disability level and symptomatology with respect to the symptoms and functional impairment she experiences. Specifically, the Veteran primarily reports urine leakage and urine frequency with daytime voiding between four to five times during the day and up to two times at night. There is no evidence to indicate that at any time during the appeal period the urine leakage required the use of absorbent materials. The current 20 percent ratings under 4.115a are specific for such symptomatology. Thus, the Veteran's current schedular ratings are adequate to fully compensate her for her disability on appeal. Under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Notably, the Veteran is also service connected for migraines, bipolar disorder, asthma, and back strain. Neither the Veteran nor her representative has indicated any specific service-connected disabilities which are not captured by the schedular evaluations of the Veteran's individual service-connected conditions. After applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), the Board finds there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of the Veteran's uterine disorder claim for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Bipolar Disorder The Veteran contends that a 50 percent disability rating is warranted. See March 2017 Informal Hearing Presentation. For the reasons explained below, the Board finds that a disability rating of 50 percent, but no higher, is warranted for the entire timeframe on appeal. The Veteran filed her claim days after discharge. The Board will briefly list out evidence that falls outside the appeal period, in an effort to capture the whole picture of her disability. Service treatment records dated October 2005 to December 2005 indicate that the Veteran often felt overwhelmed, struggled with keeping her thoughts in order, suffered memory loss, had low self-esteem, and depressed mood. October 2005 service treatment records indicate the Veteran had difficulty sleeping and dealing with life responsibilities. She reported decreased appetite, racing thoughts, decrease in concentration, hopelessness, and unhappy mood. In a questionnaire she filled out, she wrote the following: "I cry all the time, have difficulty organizing or following through, difficulty sleeping. I don't eat anymore. I cry all the time. Feel less than. I don't want to be around people. I am tired all time. Focusing is difficult." The examiner noted her thought content as very fragmented, her appearance as disheveled and untidy, cooperative and impulsive, affect anxious, with mood ranging from sad to frustrated to unstable, thought processes were tangential with loose associations, insight questionable, judgment poor, but with average intellectual function. Her psychomotor activities were noted as restless, but also alert. The examiner described the Veteran's behavior as tense and hyper at times, noting her ability to maintain focus was challenging and that she was critical of herself. No suicidal ideation or homicidal ideation was reported. November 2005 service treatment records indicate the Veteran still presented as being very critical of herself, and she still struggled with maintaining her concentration on one subject at a time. An examiner noted that her thoughts would bounce from one subject to another without her realizing that she had not finished the first subject. In a December 2005 service treatment report the Veteran described feeling insignificant, stating she had not done anything important in her life to date. No suicidal ideation or homicidal ideation was reported. The Veteran was afforded a VA examination in April 2006. She reported her history as experiencing sleep difficulties, racing thoughts, and sadness. She was diagnosed with bipolar disorder and was treated with therapy and medication. Her current symptoms were reported as racing thoughts, insomnia, and anxiety, memory loss, difficulty with concentration, fluctuating appetite and weight, having feelings of inferiority, insecurity, and guilt about her son. She stated that when she is not sleeping she feels that she has to engage in tasks such as cleaning. She described her memory problems as forgetting important things and forgetting directions to places. With respect to her social life she stated she gets together with family and talks more now. When describing her employment history, she related that she has not been in active service since January 2006, but was currently in the reserves. She reported last being employed in February 2003 as home health worker. She reported missing about 10 days when she was working because of illness. She expressed worry about her performance when she returned to work, stating, "I feel different. I am not sure of myself. I am not sure if I'd be on top of the task. I feel less efficient." She stated she is sometimes awakened by ambient noise, which then results in her thinking about nothing in particular. She reported occasional periods of euphoria and hyperactivity. She denied auditory or visual hallucinations, but reported the feeling of a presence at times. She stated her belief that she sometimes can read peoples' minds and they can read hers. She denied ever having suicidal or homicidal ideation, and when asked about a history of suicide attempts, she responded "not really." Mental status examination showed pleasant and cooperative disposition, neat appearance, spontaneous speech, appropriate to thought and content, even mood and well oriented to time, place, person and date. The examiner noted that there was no evidence of perceptual disordered thought. The Veteran was diagnosed bipolar disorder and was assigned a GAF score of 62 to 65. A September 2006 VA medical treatment note indicates the Veteran reported being raped in 1994 and how she periodically relives it, despite her attempts to shut it out of her memory. In a November 2006 VA medical treatment note, the Veteran expressed feelings of regret and blame, stating she should have done more to prevent the rape. When discussing an ex-boyfriend who left her to marry another, she described a tremendous sense of loss, stating that she "always wanted to be married." She was single, living with her 18 year old son. She reported being very spiritual and attending church. Mental status examination showed a very well groomed, attractive, nervous and anxious woman. The Veteran worried about "seeing someone I know here." Speech was within normal limits, thought processes coherent, and affect and mood were described as tearful during the entire session. The examiner noted that the Veteran works on "trying to seem normal." Her insight was listed as very little, not psychologically minded, confused by the assault and her response to it, but her judgment seems okay. Mini mental status exam was within normal limits. She was diagnosed with bipolar disorder and assigned a GAF score of 49. A December 2006 VA medical treatment note, after mental status examination, showed neutral mood, appropriate affect, mildly disorganized thought processes, insight fair, and motivation good. There was no presentation of psychotic symptoms. The Veteran was diagnosed with working bipolar. In another December 2006 VA medical treatment note, the Veteran described a breakdown she had in 1996, as a result of the rape in 1994. During this breakdown she reported experiencing racing thoughts, increased hyperactivity, and staying up for days working on projects. She reported being diagnosed with bipolar disorder being on many different antidepressants/mood stabilizers. The examiner made the following observations: well-dressed and groomed, confused, could not remember her major depressive disorder, poor personal boundaries and sense of purpose of the exam, unable to do serial 7s, unable to say how she arrived at today's appointment, crying at portions of the interview, and preoccupied with a sexual assault. The examiner noted that she was not clear how on how the Veteran functions on a daily basis. The Veteran denied suicidal or homicidal ideation. There were several visits in January 2007. These VA medical treatment notes indicate reports of significant distress, and difficulty with memory and attention. These notes indicate mood as neutral, "good" and dysthymic; affect as congruent, and appropriate; thought process as focused and coherent, fairly clear and organized, and mildly disorganized; insight good, poor and fair; motivation as good and fair. There was no presentation of psychotic symptoms. The diagnosis was consistently bipolar disorder and in one note the additional diagnosis of PTSD was noted. A GAF score of 50 was assigned. There were several visits in February 2007. These VA medical treatment notes indicate reports of significant distress, feeling overwhelmed, and racing thoughts. These notes describe her mood as dysthymic, euthymic, and neutral to dysthymic. Her affect as dysthymic and euthymic; thought process as focused and generally coherent, and somewhat focused and coherent; insight as fair and good; and motivation as good. The diagnoses were consistently bipolar disorder, chronic PTSD, and bereavement. There was no presentation of psychotic symptoms. One of the medical visits during this time resulted in the examiner describing the manifestation of the Veteran's bipolar disorder with the following symptoms: subjective experience of racing thoughts, distractibility, diminished ability to think, irritability, depressed mood most of the day nearly every day, feelings of worthlessness, excessive or inappropriate guilt, decreased need for sleep, lack of energy/fatigability nearly every day, lack of reactivity to usually pleasurable stimuli, excessive involvement in pleasurable activities with painful potential, and buying sprees. The Veteran was assigned a GAF score of 55. There were several visits in March 2007. These VA medical treatment notes indicate reports of significant distress, feeling overwhelmed, and being often being distracted. These notes indicate mood and affect as neutral to euthymic, neutral to bright, and dysthymic; thought process as focused and generally coherent; insight as fair to good, and fair; and motivation as fair. There was no presentation of psychotic symptoms. An examiner during one of these visits noted that the Veteran is easily distracted and would forget her route when driving, and has paid all of her bills late. Mental status examination showed alert, well-groomed, friendly and cooperative, psychomotor agitation observed, oriented in all spheres, and psychomotor speed and mental flexibility were mild to moderately impaired. Conversational speech normal in rate and volume, but mild, word-finding problems were noted. Visual spatial construction and visual memory intact. The examiner noted that despite reported memory deficits the Veteran's ability to learn a list of words was in the superior range. The examiner concluded that the Veteran had innate intellectual capacity and learning ability to succeed academically, but her slowed cognitive processing impeded her ability to pass her academic course. The diagnoses during these visits were bipolar, PTSD, bereavement, and cognitive slowing related to psychiatric disorder (PTSD, depression), with no evidence of dementia. In an April 2007 VA psychology progress note, the examiner noted that the Veteran became somewhat tearful when discussing the rape trauma combined with the idea of "letting herself off the hook." She appeared stable. Mood and affect were neutral to euthymic. Thought processes focused and generally coherent. Insight was fair to good. Motivation was not good. There was no presentation of psychotic symptoms. She was diagnosed with bipolar disorder, PTSD, and bereavement. During a November 2007 VA examination, the Veteran reported that she was on medications for bipolar disorder and depression. She related depression, bad dreams, and difficulty concentrating and difficulty sleeping. She reported having episodes of racing thoughts, and feeling sad and depressed. She indicated that she had recently married and that she had a hard time with intimacy with her husband. She described the relationship as stressed. This was the Veteran's first marriage. The examiner noted that the Veteran became tearful and would cry when discussing the death of her close friend or the rape. When describing her employment she reported being in the reserves and working as an LPN in home health care and that she had been doing that for 11 years. She also reported time lost from work as a few hours. The examiner found that the Veteran was oriented and appeared depressed. She had clear speech, good memory, and a depressed mood, with tearfulness when describing traumatic and upsetting events. The Veteran denied delusion, hallucinations, suicidal or homicidal thoughts. The examiner also noted recent and remote memory as good, and that the Veteran was capable of managing her benefits. There was no impairment of thought process, social functioning or post-military stressors. She was normal with respect to her activities of daily living. The examiner diagnosed the Veteran with depressed bipolar disorder and assigned a GAF score of 60. The Veteran was afforded another VA examination in February 2013. With respect to her home and work life, the Veteran indicated that she was still married, had one adult biological child, 4 non-biological children ranging in ages 9 to 17. She reported that she was unemployed and had been since November 2012, since finishing a period of active service. In describing her former employment, she stated she felt undermined by her subordinate and felt unsupported by her superiors. She stated that, "I was blamed for everything." She reported being discharged from outpatient treatment in May 2008 for nonattendance. Prior to that, she stated that she was continuing treatment with her new therapist in November 2007. She reported the following: feeling exhausted, tired almost all day about three days a week, impaired concentration, being easily distracted, irritability, and difficulty returning to sleep after awakening to urinate. She stated that she had gained weight because of overeating. She stated that she has not had a hypomanic episode since December 2012. The examiner noted that the Veteran is able to maintain daily activities, attend her children's activities, and seek employment. Mental status examination showed alert, appropriate affect, even mood, impaired concentration, but no distractibility. The examiner, when summarizing the Veteran's level of occupational and social impairment, stated that a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. The examiner diagnosed the Veteran with bipolar disorder and assigned a GAF score of 70. Upon review of the evidence, the Board finds that a 50 percent rating, but no higher, is warranted for the Veteran's bipolar disorder. During the appeal periods, the Board finds all reasonable doubt in the Veteran's favor and finds that her bipolar symptoms more nearly approximates reduced reliability and productivity required for a 50 percent rating. As noted above, the Veteran's bipolar disorder was uniformly manifested by symptoms including: sleep impairment, depressed mood, racing thoughts, significant distress, impaired concentration and some memory loss. Based on the evidence of record described above, the Board finds that throughout the appeal period, the Veteran's bipolar disorder symptoms result in occupational and social impairment, with reduced reliability and productivity, due to such symptoms as depressed mood, impairment of short term memory, and sleep impairment. Her symptoms are consistent with a 50 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9432. The preponderance of the evidence demonstrates that the criteria for a disability rating in excess of 70 percent for the Veteran's bipolar disorder have not been met at any point during the relevant appeal period. Specifically, the Veteran's bipolar disorder has not been manifested by symptomatology more nearly approximating occupational and social impairment with deficiencies in most areas. As such, the Board finds that a 70 percent disability rating is not warranted at any time during the relevant appeal period. 38 C.F.R. §4.130, Diagnostic Code 9432. In reviewing the criteria for a 70 percent disability rating and determining whether an evaluation in excess of 50 percent is warranted, the Board finds that the evidence does not establish that during the appeal period the Veteran's bipolar disorder manifested in occupational and social impairment with deficiencies in most areas. The Board notes the Veteran's contention that the Board in their September 2013 decision failed to account for her being unemployed since November 2012 and whether her unemployment was due to bipolar disorder symptoms. The Board also acknowledges the Secretary's concession that the Board should support its decision with an adequate statement of reasons that account for all of the Veteran's symptoms including the functional impact of her bipolar disorder on her activities of daily living and employability. See Brief of the Appellee submitted October 2014. Regarding these areas, the Board has fully considered the frequency, severity, and duration of all of the Veteran's psychiatric symptoms with respect to their effect on her overall occupational and social functioning. 38 C.F.R. §4.126(a). Throughout the appeal period, the Veteran has presented with normal speech, being oriented in all spheres, and being capable of taking care of her daily living activities, as well as building and maintaining lasting relationships with family. She presented with bipolar disorder throughout the examinations, with PTSD and bereavement during a few examinations. Her attitude throughout the appeal process was friendly and cooperative. Despite struggles with memory during the appeal period, her memory overall has been noted as good. In sum, her symptoms do not prevent her from functioning independently or otherwise result in occupational and social impairment with deficiencies in most areas. Upon review of the record, it is not entirely clear as to the Veteran's entire employment history. In the April 2006 VA examination she reported being last employed in February 2003 doing home health care. In the November 2007 VA examination she reported being currently employed at that time, doing home health care and doing that for 11 years. It appears that the Veteran's work history is in home health care and she was employed in February 2003, November 2007 and her employment ended in November 2012. The Veteran reported being gainfully employed for 11 years, even if not consecutively. The February 2013 VA examiner concluded that the Veteran is capable of seeking employment. The Veteran went through periods of being single and dating and then entered into her first marriage during the appeal period. Despite reporting feelings of hopelessness or isolation, she has consistently described being around family and raising her son. She expressed her desire to marry and then ultimately got married, extending her family to include her husband and four step children. At no time during the appeal period did the Veteran report or exhibit speech intermittently illogical, obscure or irrelevant, impaired spatial disorientation, or any symptoms consistent with a 70 percent disability rating. Upon review of the record as a whole it is clear that the symptoms the Veteran experiences did not cause deficiencies in most areas. None of her examinations showed symptoms consistent with occupational and social impairment with deficiencies in most areas. The April 2006 VA examiner noted that upon examination there was no evidence of perceptual disordered thought. The November 2007 VA examiner concluded that there was no impairment of thought process, social functioning or post military stressors or normal activities of daily living. The February 2013 VA examiner noted that the Veteran is able to maintain daily activities, attend her children's activities, and seek employment. The Board notes that the December 2006 VA examiner stated that the Veteran appeared to be unable to function on a daily basis. However, those symptoms she presented at that time were not noted to rise to the level of severity required for a 70 percent disability rating. The Board has considered the GAF scores assigned during the relevant appeal period. A GAF score must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. Individual GAF scores are not dispositive as to the proper disability level, and must be considered with all the evidence of record. See Cline v. Shinseki, 26 Vet. App. 18, 28 (2012) (stating that GAF scores, although potentially probative of the level of impairment caused by a mental disorder, "are not dispositive of the proper level of disability."); see also Massey v. Brown, 7 Vet. App. 204, 207 (1994). The GAF scores assigned to the Veteran's psychological profile of record, during the appeal period consist of six scores: 62 to 65, 49, 50, 55, 60 and 70. GAF scores between 61 and 70 represent mild symptoms; GAF scores between 51 and 60 represent moderate symptoms; and GAF scores between 41 and 50 represent serious symptoms. Therefore, the GAF scores assigned to the Veteran's psychological profile during the relevant appeal period are consistent with a 50 percent disability rating. In arriving at this conclusion, the Board has carefully considered the lay assertions of the Veteran as well as the argument put forward in the Appellant's Brief submitted in March 2017. In this regard, the Board finds that the Veteran's symptoms reflect occupational and social impairment with reduced reliability and productivity, but do not reflect deficiencies in most areas, even with consideration of some symptomatology thereof, because those symptoms are not shown to be of such severity to warrant a 70 percent rating. In light of the foregoing, the Board finds that the Veteran's symptoms do not more nearly approximate a rating in excess of 50 percent under the General Rating Formula. The Board has considered whether staged ratings are appropriate for the Veteran's bipolar disorder during anytime during the appeal period; however, the Board finds that her symptomatology has most nearly approximated symptoms such as those exemplified by the 50 percent disability criteria throughout the appeal period. Thus, staged ratings during any time during the appeal period are not warranted. The Board finds that the Veteran's deficiencies must be "due to" symptoms listed for that rating level, "or others of similar severity, frequency and duration. Vasquez-Claudio, 713 F.3d at 117. Here, the symptoms noted during the VA examinations during the appeal period are of similar severity, frequency, and duration of those described under the criteria for a 50 percent rating. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record)." In sum, a 50 percent rating, but no higher, is warranted for the periods on appeal. As the preponderance of the evidence is against the claim for a disability rating in excess of 50 percent, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER A disability rating of 20 percent, but no higher, from January 27, 2006, to January 6, 2011, and from December 1, 2012, to February 11, 2013, for uterine disorder is granted. A disability rating of 50 percent, but no higher, from January 27, 2006, to January 6, 2011, and from December 1, 2012, and thereafter, for bipolar disorder is granted. ____________________________________________ H.M. WALKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs