Citation Nr: 1803763 Decision Date: 01/19/18 Archive Date: 01/29/18 DOCKET NO. 14-18 694 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUE Entitlement to an initial rating in excess of 50 percent prior to May 10, 2016, and a disability rating in excess of 70 percent from that date, for service-connected anxiety with depression. REPRESENTATION Appellant represented by: Amy Fochler, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. Laroche, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Army from July 1970 to April 1972. This appeal to the Board of Veterans' Appeals (Board) arose from an April 2011 rating decision in which the RO granted service connection for anxiety disorder with depression and assigned a 50 percent disability rating, effective August 10, 2010. In June 2011, the Veteran filed a notice of disagreement (NOD) with the April 2011 decision. In July 2011, the Veteran filed a claim for a total disability rating based on individual unemployability (TDIU) due to his service-connected psychiatric disability. In April 2013, the RO issued a statement of the case (SOC) on both issues. The Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in June 2013. Because the Veteran has disagreed with the initial rating assigned following the award of service connection, the Board has characterized this claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims for claims for increased ratings for already service-connected disability). In December 2015, the Veteran testified during a Board video-conference hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the record. During the hearing, the Veteran waived initial agency of original jurisdiction (AOJ) consideration of additional evidence received after the April 2013 statement of the case. See 38 C.F.R. § 20.1304 (c) (2017). In February 2016, the Board remanded the claims to the RO, via the Appeals Management Center (AMC) in Washington, D.C., for further development. After accomplishing further action, in a January 2017 rating decision, the RO assigned a higher, 70 percent rating for anxiety with depression, effective May 10, 2016. The AMC continued to deny a disability rating higher than 50 percent prior to May 10, 2016, and higher than 70 percent from that date for the Veteran's service-connected anxiety with depression. Although the AMC awarded an increased rating for anxiety with depression from May 10, 2016, as higher ratings are available before and after that date, and a claimant is presumed to seek the maximum available benefit for a disability, the claim involving evaluation of the psychiatric disability-now characterized to reflect the staged ratings assigned-remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Additionally, as regards the claim of entitlement to a TDIU, that matter was granted by a decision review officer (DRO) in the January 2017 rating decision. A disability rating and effective date was also assigned in connection with that award. To date, the appellant had not disagreed with any aspect of that decision. That matter has accordingly been resolved. See Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997) (where an appealed claim is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of the award). As for the matter of representation, the Board points out that the Veteran was previously represented by agent Christopher Loiacono, as reflected by a May 2011 VA Form 21-22a, Appointment of Individual as Claimant's Representative. Subsequently, the Veteran appointed private attorney Amy Fochler as his representative, as reflected by a September 2015 VA Form 21-22a,. The Board has recognized the change in representation While the Veteran previously had a paper claims file, this appeal is now being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Legacy Content Manager (Virtual VA) claims processing systems. All records have been reviewed. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matter herein decided have been accomplished. 2. From the August 10, 2010 effective date of the award of service connection to May 10, 2016, the Veteran's psychiatric symptoms primarily included anxious and depressed mood, occasional to frequent panic attacks, mildly impaired memory, sleep impairment, a suicide attempt and suicidal ideation, and difficulty with concentration; collectively, these symptoms are of the type and extent, frequency or severity that suggest occupational and social impairment with moderate to severe deficiencies in most areas such as work, family relations, and judgment. 3. Since May 10, 2016, the Veteran's psychiatric symptoms primarily included anxiety with depressed mood, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, decreased motivation, and isolation; collectively, these symptoms are of the time and extent, frequency or severity, that are indicative of no more than occupational and social impairment with moderate to severe deficiencies in most areas such as work, family relations, and judgment. 4. The schedular criteria are adequate to evaluate the Veteran's anxiety with depression at all pertinent points. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 70 percent rating for anxiety with depression, from August 10, 2010 to May 10, 2016, are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for a rating in excess of 70 percent for anxiety with depression are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). After a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103 (a) and 38 C.F.R. § 3.159 (b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In an October 2010 pre-rating letter sent to the Veteran in connection with his claim, the AOJ provided notice to the Veteran explaining what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. This letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. Furthermore, as the current appeal of anxiety with depression emanated from the Veteran's disagreement with the initial rating assigned following the awards of service connection, no additional VCAA notice letter notice for the downstream higher rating issue was required under 38 U.S.C. § 5103A. See VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004)). However, the April 2013 SOC set forth the criteria for a higher rating for anxiety with depression (the timing and form of which suffices, in part, for Dingess/Hartman). The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the Veteran's claim, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of service records; VA treatment records; and reports of VA examinations and opinions with a private psychiatric medical assessment. Also of record and consistent with the claim is the transcript of the Board hearing, along with written statements by the Veteran and by his representative on his behalf. The Board finds that no further AOJ action on this claim, prior to appellate consideration, is required. As noted, the Veteran had an opportunity to orally advance his contentions during a Board hearing. During the December 2015 Board hearing, the undersigned identified the claims on appeal, to include the claim herein decided. Moreover, with respect to this claim, information was elicited regarding the nature of the disability, current severity, and treatment. Although the undersigned did not explicitly suggest the submission of any specific additional evidence, on these facts, such omission was harmless. After the hearing, the Board sought further development of the claim, as the result of which additional evidence was added to the claims file. Thus, the hearing was legally sufficient. See 38 C.F.R. § 3.103 (c)(2) (2016); Bryant v. Shinseki, 23 Vet. App. 488 (2010). As indicated above, in February 2016, the Board remanded the claim on appeal for additional development, and the record reflects substantial compliance with the prior remand directives as to the claim for an increased disability rating for a psychiatric disability. See Stegall v. West, 11 Vet. App. 268 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) and Dyment v. West, 13 Vet. App. 141, 146-47 (1999) aff'd, Dyment v. Principi, 287 F.3d 1377 (2002) (holding that substantial, rather than strict, compliance is sufficient). As indicated above, in January 2015 and September 2016, the Board remanded the claim on appeal for additional development, and the record reflects substantial compliance with the prior remand directives with respect to the increased rating claim. See Stegall v. West, 11 Vet. App. 268 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) and Dyment v. West, 13 Vet. App. 141, 146-47 (1999) aff'd, Dyment v. Principi, 287 F.3d 1377 (2002) (holding that substantial, rather than strict, compliance is sufficient). In this regard, as directed by the Board, the AOJ located and associated with the claims file the Veteran's June 2011 NOD, obtained outstanding VA records, invited the Veteran to identify, or provide records from, any additional sources of treatment (no private treatment records were identified or provided), and, in July 2016, a psychiatric VA examination was conducted and the examiner provided an appropriate medical opinion. Moreover, after receipt of the VA examination report and opinion, and additional VA records, the AOJ readjudicated the claim, as directed (as reflected in the February 2017 supplemental SOC (SSOC)). In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim herein decided. As such, the Veteran is not prejudiced by the Board proceeding to a decision on the claim, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, an initial 50 percent rating for the Veteran's anxiety with depression has been assigned from the August 10, 2010, effective date of award of service connection to May 10, 2016. As noted above, during the pendency of the appeal, the RO assigned a higher disability rating of 70 percent from May 10, 2016. Although both ratings were assigned under DC 9411, the actual criteria for rating psychiatric disabilities other than eating disorders are set forth in a General Rating Formula for Mental Disorders (General Rating Formula). See 38 C.F.R. § 4.130. Under the General Rating Formula, 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for 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); and an inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. As the United States Court of Appeals for the Federal Circuit has explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). However, the symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas"-i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130. When evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). Historically, psychiatric examinations frequently included assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (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 the 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). [Parenthetically, the Board notes that the revised DSM-5, which among other things, eliminates GAF scores, applies to claims certified to the Board after August 4, 2014. See 79 Fed. Reg. 45, 093 (Aug. 4, 2014).] Turning to the relevant evidence of record, VA mental health treatment records dated in August 2010 reflect an assessment of depression. The Veteran's mood was observed to be fair and he reported that he was doing well with medication. The Veteran denied suicidal/homicidal ideation and auditory/visual hallucination. The examiner noted that the Veteran's thought processes were normal; he was oriented to self, time, and place; and he had no reckless behavior, social withdrawal, or racing thoughts. The Veteran underwent a January 2011 VA examination for his psychiatric disability. He then reported that he had two prior suicide attempts; the last one was in 1995. He denied current suicidal ideation or plans. The examiner noted that the Veteran had a general appearance that was appropriate; hesitant but clear speech; constricted affect; anxious mood; and moderate impairment in social recreational and familial adjustment. The Veteran's attention was noted as easily distracted with a short attention span-he complained of difficultly with focusing and concentration. The examiner noted that the Veteran was intact to person, time, place; had no delusions; understood outcomes of his behavior; chronic sleep impairment; no hallucinations; no obsessive, ritualistic, and inappropriate behavior; occasional moderate to severe panic attacks; no homicidal thoughts; occasional suicidal thoughts but no plans to harm himself; good impulse control; and mildly impaired memory. VA mental health treatment notes from February 2011 reflect that the Veteran denied auditory/visual hallucinations and paranoia/delusions. Additionally, he denied suicidal/homicidal ideation. The examiner noted that the Veteran did not report recklessness, racing thoughts, and social withdrawal. The examiner reported that the Veteran's thought processes were normal. Psychiatric treatment records from Wesley Long Hospital reflect that the Veteran was hospitalized on July 19, 2011 for a suicide attempt. At that time, the Veteran reported that his depression had been worsening. The physician noted that the Veteran committed himself voluntary; however, his insight was poor and he required inpatient psychiatric assessment and therapy. In October 2011, the Veteran was seen by Dr. K. H. for a psychiatric/psychological impairment assessment. Dr. K.H. indicated that the Veteran exhibited intermittent inability to perform activities of daily living; deficiencies in family relations; deficiencies in mood; persistent irrational fears; difficulty in adapting to stressful circumstances; deficiencies in work or school; inability to establish and maintain effective relationships; depression affecting the ability to function independently, appropriately, and effectively; deficiencies in judgment; and suicidal ideation. Dr. K.H. also reported that the Veteran had agoraphobic behaviors which she classified as isolated. She reported that the Veteran had severe impairment in social and occupational functioning due to his psychiatric symptoms. VA mental health notes from 2013 reflect that the Veteran continued to deny suicidal and homicidal ideation. He continued to have increased anxiety with others around, but was not limiting himself to his house. His thought processes remained coherent, relevant, logical, and goal-directed. The psychologist consistently noted that his judgment and insight were intact. The psychologist noted that the Veteran had positive future plans, positive social support, a sense of responsibility to family and his significant other, life satisfaction, positive coping skills, positive problem-solving skills, and positive therapeutic relationship. The Veteran's GAF scores fluctuated between 55 and 65. On February 2013, the examiner reported that psychotherapy and medication indicated that the Veteran's condition was improving and he was noted to be stable. The Veteran reported that he had suicidal thoughts in the past but did not have current suicidal thoughts at the time of the examination. Additionally, he reported that he never thought about hurting anyone else. The Veteran reported sleep impairment; depressed mood; anxiety; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances, including work or a work like setting. The Veteran was assigned a GAF score at 55. VA psychiatric treatment notes from March 2015 reflect that the Veteran denied thoughts/intent/plan for violence towards self and others. The Veteran reported that he felt anxious each day and had panic attacks, intrusive thoughts of his time in the military, sleep impairment, and that he was uncomfortable in social situations. During the December 2015 Board hearing, the Veteran testified that he had multiple suicide attempts; a lack of friendships; feelings of distrust; avoidance of crowds; panic attacks; seeing and hearing things; sleep impairment; dreams or nightmares; failed memory and disorientation; and suicide thoughts once or twice a month. He reported that his symptomatology at the time of the hearing mirrored his symptomatology in 2011-specifically, his symptoms as noted in the October 2011 assessment by Dr. K.H. A December 2015 VA suicide risk assessment reflects that the Veteran did not demonstrate signs or symptoms indicative of suicidal ideation or behavior. On June 2016 VA examination, the Veteran reported that the anxiety and depression "got to the point where [he] had a hard time controlling his temper." He reported that he did not want to leave his house anymore and he could not be around people. He further reported that he was hospitalized in 2012 for self-mutilating behavior that included cutting his arms. The Veteran's symptoms were identified as depressed mood; anxiety; suspiciousness; panic attacks that occurred weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships. At the time of the evaluation, the Veteran's mood was described as anxious; he was fully oriented; affect was normal; memory functioning was intact for remote and recent events; his thought processes were intact; and he reported no hallucinations, delusions, phobias, obsessions/compulsions, suicidal ideation, or homicidal ideation. The examiner found that he demonstrated good judgment and insight. An October 2016 VA mental health note reflects that the Veteran denied psychotic symptoms (delusions, paranoia) as well as suicidal and homicidal ideation. The Veteran endorsed avoidance symptoms; he reported that he avoided crowds. He reported that his anxiety was at a 10 out of a scale of 1-10 with 10 being the highest. He was oriented to person, place, time, and situation with a congruent mood. Considering the pertinent evidence in light of the applicable legal authority, and resolving all reasonable doubt in the Veteran's favor, the Board finds that, for the period from August 10, 2010 to May 10, 2016, an initial 70 percent, but no higher, rating for service-connected anxiety with depression is warranted.. For this period, the medical evidence of record reflects that the Veteran's psychiatric disability was manifested by symptoms such as the following: anxious and depressed mood, occasional to frequent panic attacks, mildly impaired memory, sleep impairment, difficulty with concentration; some social isolation and avoidance; deficiencies in family relationships; persistent irrational fears; and most significantly, suicidal ideation with suicide attempts within the period of appeal. Medical records from Wesley Long Hospital document the Veteran's hospitalization in July 2011 as a result of a suicide attempt and worsened depression. Additionally, the Veteran reported during his June 2016 VA examination that he was hospitalized in 2012 for cutting his arms. However, VA examination reports and statements from the Veteran reflect that he denied current suicidal ideation or plans. After his suicide attempt in July 2011, psychiatric medical records reflect that the Veteran continued to deny suicidal and homicidal ideation. Examination reports consistently found the Veteran to be oriented to time, place, and person; his speech and thought processes were normal; his judgment and insight were continually noted as "good;" and he did not demonstrate persistent delusions or hallucinations. Collectively, these symptoms are of the type and extent, frequency, and/or severity (as appropriate) that are indicative of no more than occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood. In sum, for this period, there were symptoms listed among both the criteria for the 50 percent and the 70 percent rating, indicating moderate to severe impairment of social and occupational functioning, the Board finds that the evidence is relatively evenly balanced on the question of whether the Veteran's psychiatric disability initially resulted in a level of occupational and social impairment which more closely approximated a 70 percent disability rating for the initial rating period from the effective date of the award of service connection to May 10, 2016. Accordingly, the Board has resolved all reasonable doubt in the Veteran's favor in awarding the higher, 70 percent rating for this period. However, the Board finds that the Veteran's psychiatric disability has not met, or more closely approximated, the criteria for the maximum, 100 percent rating at any point since the effective date of the award of service connection. In this regard, at no point has the Veteran manifested 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. The Board notes that the Veteran was hospitalized as a result of a suicide attempt in 2011; however, the Veteran's VA treatment notes and VA examination reports specifically note that his suicidal ideation was without any intent to act, indicating no danger, let alone persistent danger, of the Veteran hurting himself or others. Mental health treatment notes dated in 2013 reflect the Veteran's positive future plans and support system. The Board specifically notes the treatment records available after the Veteran's 2011 hospitalization-primarily, his December 2015 suicide risk assessment which was negative for signs or symptoms indicative of suicidal ideation or behavior, the February 2013 VA examination report where the examiner indicated the Veteran's improvement, and the June 2016 VA examination report where the Veteran explicitly denied current suicidal ideation or plans. Additionally, the Board notes that during the December 2015 Board hearing, the Veteran testified to "seeing and hearing things." However, VA treatment notes and VA examination reports reflect that the Veteran consistently denied having hallucinations or delusions. The medical record also reflects that the Veteran was always oriented to time and place and otherwise had coherent speech and thought processes. It has also been consistently indicated that the Veteran is able to perform activities of daily living, has adequate hygiene, and has no inappropriate behavior. Thus, the Board finds that at no pertinent point has the Veteran manifested symptoms of the type, and extent, frequency, and/or severity (as appropriate) contemplated by the maximum, 100 percent schedular rating. The Board further finds that none of the assigned GAF scores alone provide a basis for a higher 100 percent rating. As noted above, the Veteran has been assigned GAF scores ranging from 55 to 65. Under the DSM-IV, GAF scores ranging from 51 to 60 indicate moderate symptoms (e.g. flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging from 61 to 70 are indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupation, or school functioning (e.g., occasional truancy, or then within the household) but generally functioning pretty well, has some meaningful interpersonal relationships. As noted above, assigned GAF scores are not dispositive; but, rather, must be considered in the light of the actual symptoms shown. Here, GAF scores predominately in the 50 range were assigned during a period in which the Veteran endorsed symptoms of chronic sleep impairment, depression, anxiety, and social difficulties, which the Board has determined warrants an initial 70 percent rating. As the assigned GAF scores reflect even less impairment that that contemplated in the initial 70 percent rating herein granted, they clearly provide no basis for an even higher rating. The above determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point since the effective date of the award of service connection has the Veteran's psychiatric disability been shown to present so exceptional or so unusual a picture as to render the applicable criteria inadequate, and to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321 (b)(1). The threshold factor for extra-schedular consideration is a finding on the part of the AOJ or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the AOJ or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321 (b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, 22 Vet. App. at 111. In this case, the Board finds that the schedular criteria are adequate to rate the Veteran's service-connected anxiety with depression at all pertinent points. The Veteran's symptoms, as discussed above, are all contemplated by the appropriate rating criteria under the General Rating Formula. Specifically, the General Rating Formula provides compensation based upon the extent to which all psychiatric symptoms result in social and occupational impairment. The criteria in the General Rating Formula include both the symptoms listed as symptoms "such as" those listed, along with the overall impairment caused by these symptoms. This broad language in the criteria thus contemplates all of the symptoms even though they are not specifically listed, and Veteran has not demonstrated or alleged any symptomatology that falls outside the scope of the applicable criteria. In short, the rating schedule fully contemplates the type and extent, frequency or severity of described symptomatology associated with mood disorder, and provides for higher ratings based on more significant impairment. Notably, there is no indication or argument that the applicable criteria are otherwise inadequate to rate the disability. The Board further notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. Here, however, the Veteran's anxiety with depression is appropriately rated as a single disability, and his psychiatric symptoms have been considered in the evaluation of the disability. The Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance so as to render the schedular rating criteria for evaluating the disability inadequate. See Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016). Accordingly, this is not an exceptional circumstance for extra-schedular consideration within the meaning of Johnson. As the requirements for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) for assignment of a higher, extra-schedular rating are not met, referral of this matter for extra-schedular consideration is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds there is no basis for staged rating of the disability, and that while the criteria for an initial 70 percent rating for the Veteran's anxiety with depression are met from August 10, 2010 to May 10, 2016, a rating in excess of 70 percent must be denied. The Board has resolved reasonable doubt in the Veteran's favor in assigning a higher initial 70 percent rating for anxiety with depression, from August 10, 2010 to May 10, 2016, but finds that the preponderance of the evidence is against assignment of any higher rating at any pertinent point. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial 70 percent rating for anxiety with depression, from August 10, 2010 to May 10, 2016, is granted, subject to the legal authority governing the payment of VA compensation. A rating in excess of 70 for anxiety with depression is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs