Citation Nr: 21002781 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 18-41 019 DATE: January 14, 2021 ORDER Service connection for seborrheic dermatitis, claimed as a skin disability, is denied. A 10 percent rating for postoperative tonsillitis and pharyngitis is granted. A rating in excess of 30 percent for residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion is granted. An initial rating in excess of 20 percent for gastritis is denied. An initial rating in excess of 30 percent for an unspecified anxiety disorder is denied. FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran’s seborrheic dermatitis is related to service. 2. The competent and probative medical evidence shows the Veteran’s tonsillitis and pharyngitis are manifested by occasional sore throats and hoarseness with inflammation of vocal cords. 3. The competent and probative medical evidence shows that the Veteran has ankylosis in his metacarpophalangeal and interphalangeal joints in extension and that his gripping is limited such as to equate to amputation. 4. The weight of the evidence is against a finding that the Veteran has anemia or weight loss because of his gastritis; recurrent incapacitating episodes have not been shown. 5. Throughout the rating period on appeal, the Veteran’s anxiety has been manifested by occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, due to symptoms such as depressed mood, anxiety, and chronic sleep impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for seborrheic dermatitis, claimed as a skin disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for a 10 percent disability rating for postoperative tonsillitis and pharyngitis have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.97, Diagnostic Code (DC) 6599-6516. 3. The criteria for a rating in excess of 30 percent for residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DCs 5010-5224, 5152. 4. The criteria for an initial rating in excess of 20 percent for gastritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, DC 7305. 5. The criteria for an initial rating in excess of 30 percent for an unspecified anxiety disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, DC 9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from October 1955 to October 1957. These matters came before the Board of Veterans’ Appeals (Board) on appeal from August 2017 and February 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In an October 2018 decision, the Board denied service connection for seborrheic dermatitis and denied increased ratings for postoperative tonsillitis and pharyngitis; residuals of a fracture of the right thumb; gastritis; and, unspecified anxiety disorder. The Veteran filed an appeal with the United States Court of Appeals for Veterans Claims (Court) and pursuant to a July 2019 Joint Motion for Remand (JMR) and Court Order, the Board’s decision was vacated and remanded for action consistent with the JMR. The Veteran died in February 2019. In September 2019, the appellant, the Veteran’s spouse, requested to be substituted as the appellant for purposes of processing the appeal to completion. 38 U.S.C. § 5121A; 38C.F.R. §3.1010. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be 1) evidence of a current disability; 2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and 3) causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 5758 (1990). Service connection is claimed for a skin disorder, to include seborrheic dermatitis. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of seborrheic dermatitis and had a separate skin disorder while in service, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of seborrheic dermatitis began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). VA treatment records show the Veteran was not diagnosed with seborrheic dermatitis until 2008, more than 50 years after his separation from service. While the Veteran is competent to report having to use topical treatment consistently for his skin disability after service, he is not competent to determine that these symptoms were manifestations of rubella, which was documented in service, or were otherwise related to his service. The issue is medically complex and requires expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Furthermore, the January 2018 VA examiner opined that the Veteran’s seborrheic dermatitis is not at least as likely as not related to an in-service injury, event, or disease, including rubella. The examiner reasoned that was he was not noted to have seborrheic dermatitis until 2008, and service treatment records did not show seborrheic dermatitis. Therefore, the examiner concluded that his seborrheic dermatitis was less likely than not related to service. In September 2020, the same VA examiner review the Veteran’s claims folder and noted that seborrheic dermatitis was diagnosed in 2008, which was based on review of treatment records. The examiner stated that seborrheic dermatitis was diagnosed on October 15, 2008 by the Veteran’s primary care physician. See 08/19/2020 CAPRI at 279. The examiner opined that his seborrheic dermatitis was less likely than not due to service as available service treatment records do not show complaints, diagnosis or treatment of his seborrheic dermatitis during his period of active duty or within a year from his discharge. The separation examination dated in June 1957 describes normal skin. See 04/08/2014 STR-Medical at 28. On the Report of Medical History, the Veteran did not have any skin related complaints. Id. at 16. Medical records do not show complaints, diagnosis or treatment of his seborrheic dermatitis until its diagnosis in 2008. The examiner’s opinions are probative, because they are based on an accurate medical history and the collective opinions provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, the Board notes that there is no competent and probative evidence that shows that the Veteran’s disability is at least as likely as not related to service. There is no contrary opinion of record, nor does the record contain credible evidence of continuity of symptomatology. After review of the competent and probative evidence, the Board finds that the record is against service connection for a seborrheic dermatitis. The Board acknowledges the claimant’s belief that the Veteran’s skin disability is related to service. However, neither the Veteran nor the claimant have been shown to possess the requisite expertise to diagnose symptoms the in-service symptoms or to relate the later-diagnosed dermatitis with the in-service finding of rubella. The VA examiner provided the only competent evidence in this regard. For the above reasons, reasonable doubt does not arise, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). However, a veteran may be entitled to a higher disability evaluation than that supported by mechanical application of the rating schedule where there is evidence that his or her disability causes “additional functional loss i.e., ‘the inability... to perform the normal working movements of the body with normal excursion, strength, speed, coordination[,] and endurance’ including as due to pain and/or other factors” or “reduction of a joint’s normal excursion of movement in different planes, including changes in the joint’s range of movement, strength, fatigability, or coordination.” Lyles v. Shulkin, 29 Vet. App. 107, 117-18 (2017) (quoting 38 C.F.R. § 4.40 and citing 38 C.F.R. § 4.45); Mitchell v. Shinseki, 25 Vet. App. 32, 36-37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). Postoperative tonsillitis and pharyngitis Chronic tonsillitis is rated 0 (zero) percent disabling pursuant to Diagnostic Code 6599-6516 for postoperative tonsillitis and pharyngitis. Under Diagnostic Code 6516 (chronic laryngitis), a 10 percent rating is assigned where there is evidence of hoarseness, with inflammation of cords or mucous membranes. A maximum 30 percent rating is warranted where there is evidence of hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. An April 2015 VA outpatient treatment record reflects that the Veteran sought treatment for vertigo and a fall due to dizziness; such record reflects the Veteran’s complaints of chronic hoarseness. 08/17/2017 CAPRI at 586. Subsequent treatment records dated in May 2015, July 2015, October 2015, February 2016, June 2016, November 2016, July 2017, January 2018, June 2018 reflect that the ‘hoarseness’ box is not checked with regard to the ‘Mouth and Throat’ and examinations were negative. Id. at 69, 106, 151, 202, 218, 241, 257, 376, 430; 11/17/2020 CAPRI at 745, 777. The Veteran underwent a VA examination in December 2017 for his tonsillitis and pharyngitis. At the time, he reported occasionally having a sore throat. Objective findings were limited. 11/17/2020 CAPRI at 811. Another VA examination was performed in January 2018. At this time, the Veteran stated that his condition was unchanged, and that he still had a sore throat on occasion. He did not have chronic laryngitis and had not had a laryngectomy. With regard to symptoms of the larynx and pharynx, the box for hoarseness was not checked. He acknowledged on and off pharyngitis. The examiner recorded that there was no physical evidence of active pharyngitis, and that the tonsils were absent. In October 2020, a VA examiner conducted a review of the treatment records. The examiner indicated that the Veteran had been diagnosed with chronic tonsillitis and had symptoms of hoarseness and inflammation of vocal cords. The examiner stated that there is no clinical correlation of postoperative tonsillitis and pharyngitis that were not manifested by laryngeal inflammation and premalignant changes. The Veteran’s limitations were mild, minimal with no supporting speech evaluation for moderate to severe dysphonia. The examiner stated that post-operative tonsillitis was not present in the Veteran per examination in February 2015. Pharyngitis was secondary to reflux supported by esophagogram with sliding hiatal hernia and gastric reflux in December 2014. There was no vocal cord pathology though reflux can cause vocal cord edema. A November 2018 pet scan was negative for laryngeal inflammation. After review of the competent and probative evidence, the Board finds that a 10 percent disability is warranted for the Veteran’s complaints of a sore throat and hoarseness with inflammation of vocal cords. The August 2020 examiner seemed to indicate that there was no relationship between the claimed chronic tonsillitis and pharyngitis and any laryngeal inflammation, and that the post-service pharyngitis was due to reflux. However, in the examination report, which was based on a review of the record, the examiner indicated symptoms of hoarseness and inflammation of vocal cords, both symptoms of which are included in the evaluation for pharyngitis. Affording the benefit-of-the-doubt, the Board finds that a 10 percent rating is warranted in light of the medical evidence of a sore throat and hoarseness with inflammation of vocal cords that may be associated with his chronic tonsillitis and pharyngitis. A 30 percent rating is not warranted as the medical evidence of record does not reflect hoarseness with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. Residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion The Veteran’s right thumb is rated 20 percent disabling pursuant to Diagnostic Codes 5010-5224 for residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Diagnostic Code 5010 provides that traumatic arthritis is rated as for degenerative arthritis. Diagnostic Code 5224, ankylosis of the thumb, provides a 10 percent rating for favorable ankylosis, and a 20 percent rating for unfavorable ankylosis. These ratings are assigned for both the major (dominant) and minor (non-dominant) hand. In classifying the severity of ankylosis of the thumb, the following rules are set forth in 38 C.F.R. § 4.71a: (i) Ankylosis of both the carpometacarpal and interphalangeal joints, with either joint in extension or in full flexion or with rotation or angulation of a bone, is to be rated as amputation at metacarpophalangeal joint or through proximal phalanx; (ii) Ankylosis of both the carpometacarpal and proximal interphalangeal joints, even though each is individually in favorable position, is to be rated as unfavorable ankylosis; (iii) With only the carpometacarpal or interphalangeal joint of a thumb ankylosed, and there is a gap of more than 2 inches between the thumb pad and fingers, with the thumb attempting to oppose the fingers, is to be rated as unfavorable ankylosis; and (iv) With only the carpometacarpal or interphalangeal joint of a thumb ankylosed, and there is a gap of 2 inches or less between the thumb pad and fingers, with the thumb attempting to oppose the fingers, is to be rated as favorable ankylosis. 38 C.F.R. § 4.71a. For Diagnostic Code 5152, contemplating amputation of the thumb, for the major hand, a 20 percent rating is warranted for amputation of the thumb at the distal joint or through the distal phalanx. A 30 percent rating is warranted for amputation of the thumb at the metacarpophalangeal joint or through the proximal phalanx, and a maximum 40 percent rating is warranted for amputation of the thumb with metacarpal resection. 38 C.F.R. § 4.71a, Diagnostic Code 5152. The Veteran underwent a VA examination for his right thumb disability in June 2017. He is right hand dominant, and he reported flare-ups where he would have difficulty writing or with right hand movements. He also acknowledged functional loss in that he had difficulty with grabbing objects with his right hand. He had limitation of motion in his fingers in that his thumb had maximum flexion and extension of zero degrees. His fingers all had maximum extension and flexion of 10 degrees. He had a gap between the pad of his thumb and fingers of 6.0 centimeters. He had pain that caused functional loss as well as localized tenderness or pain on palpation. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or range of motion afterwards. While the Veteran was not examined immediately after repetitive use over time, the examiner recorded that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to determine whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. In support, the examiner explained that pain could significantly limit functional ability. Moreover, while the Veteran was not examined during a flare-up, the examiner recorded that the examination was medically consistent with the Veteran’s statements describing functional loss during flare-ups. The examiner was unable to determine whether pain, weakness, fatigability or incoordination significantly limited functional ability during flare-ups as it would be speculative. The Veteran had reduced muscle strength (2/5) but did not have muscle atrophy. He had ankylosis in his metacarpophalangeal joint and interphalangeal joint in extension. Arthritis was documented in multiple joints of the Veteran’s right hand. The functional impact noted difficulty in pinching and grabbing, as well as the inability to complete a full hand grip. The examiner found there was no evidence of pain on passive range of motion or when used in non-weight bearing of the left hand. The Board observes that the examination report does not include the passive range of motion for the right hand but does for the left hand. Passive ROM is the amount of motion possible when an examiner moves a body part with no assistance from the individual being evaluated. It is usually greater than active ROM because the integrity of the soft tissue structures does not dictate the limits of movement. Comparisons between passive ROM and active ROM provide information about the amount of motion permitted by the associated joint structures (passive ROM) relative to the individual’s ability to produce motion at a joint (active ROM). Cynthia Norkin & D. Joyce White, Measurement of Joint Motion: A Guide to Goniometry 8-9 (2016). Here, there is no indication that passive ROM in this case would be more limited than active. As such, the Board concludes that the absence of findings related to passive ROM does not render the available evidence inadequate for rating purposes and will evaluate the Veteran’s joint range of motion based on the measurements recorded for active ROM and look at the Veteran’s total right-hand disability picture. In November 2020, the same VA examiner reviewed the claims folder and noted that the June 2017 examination report indicated unfavorable ankylosis of the interphalangeal joint of the thumb and that it was in extension. While not mentioned in the 2020 examiner’s review, the 2017 examination also referenced ankylosis of the MCP joint. The examiner indicated that the Veteran had difficulty with pinching and grabbing objects (i.e. to inject medication) and was unable to complete a full hand grip for activities of daily living. He was not found with any neurological symptomatology associated with the thumb. After review of the competent and probative evidence, the Board finds that a rating of 30 percent, but no higher, is warranted. Under Diagnostic Code 5152, a 30 percent rating is warranted for amputation at the metacarpophalangeal joint for the major hand, which is the Veteran’s right hand. While there appears to be some inconsistency in the record, the June 2017 VA examination, and November 2020 addendum report, reflects that there was ankylosis in both the MCP and IP joints in extension. Ankylosis of the carpometacarpal joint, with the resultant limitations in gripping, is found to most nearly approximate the 30 percent for amputation. The disability picture is not equivalent to amputation of the thumb with metacarpal resection, and as such the next-higher 40 percent rating is not for application. Lastly, the weight of the evidence does not support a finding that the Veteran’s disability picture due to functional loss/limitations or flare-ups with limitation of motion is more nearly approximated by a higher rating. Considering the Deluca and Mitchell factors, and the evidence of record, the Board finds that the current rating already compensates the Veteran for any functional loss due to pain affecting the right thumb, to include pain and limited motion. Deluca, 8 Vet. App. at 204-07. In light of the foregoing, the Board finds that an increased rating due to functional impairment would not be appropriate under the criteria for 38 C.F.R. §§ 4.40 and 4.45. Gastritis The Veteran’s gastritis is rated 20 percent disabling pursuant to Diagnostic Code 7305 for gastritis associated with residuals of a right thumb fracture. The rating criteria for duodenal ulcers provides that a severe duodenal ulcer is manifested by symptomatology including pain that is only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health, and is evaluated as 60 percent disabling. A moderately severe duodenal ulcer is manifested by symptomatology that is less than severe, but with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year, and is evaluated as 40 percent disabling. A moderate duodenal ulcer has recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations, and merits a 20 percent evaluation. A mild duodenal ulcer with recurring symptoms once or twice a year merits a continuation of the 10 percent evaluation currently in effect. 38 C.F.R. § 4.114, Diagnostic Code 7305. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The Veteran underwent a VA examination for his gastritis in June 2017. He reported nausea and heartburn, and that his symptoms worsened when he takes pain medication. He continuously took Ranitidine 150 mg. He had recurring episodes (four or more) of symptoms that are not severe yearly. He has periodic abdominal pain that is only partially relieved by standard ulcer therapy. He has recurrent nausea, with one episode of nausea per year that lasts less than one day. He denied incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. The clinical records, both VA and private, have been reviewed but fail to contain findings referable to the Veteran’s gastritis. After review of the competent and probative evidence, the Board finds that a rating in excess of 20 percent disabling for gastritis is not warranted. Indeed, the Veteran does not have anemia or weight loss because of his gastritis. Nor does he have recurrent incapacitating episodes that average 10 days or more in duration that occur at least four times per year. Rather, the competent and probative evidence reflects that he does not have any incapacitating episodes due to a stomach or duodenum condition. In sum, the Veteran’s gastritis is more nearly approximated by the current rating throughout the period on appeal. Unspecified anxiety disorder Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. “A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran’s service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). A 30 percent disability rating is warranted when there is occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if the disability is productive of 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula, the criteria for a 70 percent rating are: occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria for a 100 percent rating are: 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 hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. In June 2017, the Veteran underwent a VA examination. It was reported that he had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. He had depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. He had adequate hygiene, and good eye contact. His thought process was coherent and logical. His affect was appropriate, and he was oriented. His judgment was good and his insight was adequate. No delusions or hallucinations were reported. While his mood was depressed, he did not have suicidal ideations. He lived with his wife. Clinical records addressing other disorders indicate that the Veteran was generally accompanied by his wife and that he was cooperative. The Veteran’s treatment records reflect a consistent denial of suicidal and homicidal ideations. (Continued on the next page)   After review of the competent and probative evidence, the Board finds that the Veteran’s anxiety is most nearly approximated by the criteria for a 30 percent rating for the period on appeal. The examiner noted that he had occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran did not have panic attacks, nor did he have impaired memory or judgment. He did not have suicidal or homicidal ideations. While he had depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood, his thought process was coherent and logical, and he had adequate insight. Moreover, he did not have delusions or hallucinations. While the clinical records fail to provide much additional information, they do suggest a positive relationship with his wife, who was noted as being his support system. Overall, the Board finds that the frequency and severity of such symptoms does not more nearly approximate occupational and social impairment with reduced reliability and productivity such as to enable assignment of the next-higher 50 percent evaluation. Accordingly, the claim for increase is denied. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.