Citation Nr: 21067283 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 17-28 800A DATE: November 3, 2021 ORDER Entitlement to an initial disability evaluation rating in excess of 10 percent for degenerative arthritis of the thoracolumbar spine is denied. Entitlement to an initial rating in excess of 10 percent disabling for DeQuervain's tenosynovitis of the right wrist is denied. Entitlement to an initial rating in excess of 10 percent disabling for DeQuervain's tenosynovitis of the left wrist is denied. Entitlement to a separate rating for service connection for painful limitation of motion of the right thumb as residual of service-connected DeQuervain's tenosynovitis of the right wrist is granted, subject to regulations governing the payment of monetary awards. Entitlement to a separate rating for service connection for painful limitation of motion of the left thumb as residual of service-connected DeQuervain's tenosynovitis of the left wrist is granted, subject to regulations governing the payment of monetary awards. Entitlement to an initial rating in excess of 10 percent disabling for right plantar fasciitis is denied. Entitlement to an initial rating in excess of 10 percent disabling for cranial nerve V sensory dysfunction, status post mandibular branch injury is denied. Entitlement to an initial rating in excess of 50 percent disabling for posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. The Veteran's thoracolumbar spine has full range of motion. 2. The Veteran's right wrist symptomatology has most nearly approximated painful motion. 3. The Veteran's left wrist symptomatology has most nearly approximated painful motion. 4. The Veteran has painful motion and functional loss of the right thumb due to her DeQuervain's tenosynovitis. 5. The Veteran has painful motion and functional loss of the left thumb due to her DeQuervain's tenosynovitis. 6. The Veteran's right plantar fasciitis was manifested by pain on manipulation and pain accentuated on use; it was not manifested by marked abduction, marked pronation, swelling, callosities, extreme tenderness of plantar surfaces of the feet, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. 7. The Veteran's cranial nerve impairment is manifested by moderate incomplete paralysis of the trigeminal nerve. 8. The Veteran's PTSD manifests as occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability evaluation rating in excess of 10 percent for degenerative arthritis of the thoracolumbar spine have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 2. The criteria for entitlement to an initial rating in excess of 10 percent disabling for DeQuervain's tenosynovitis of the right wrist have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. 3. The criteria for entitlement to an initial rating in excess of 10 percent disabling for DeQuervain's tenosynovitis of the left wrist have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. 4. The criteria for entitlement to service connection for painful motion of the right thumb as a residual of the service-connected DeQuervain's tenosynovitis of the right wrist are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310; Diagnostic Code 5228. 5. The criteria for entitlement to service connection for painful motion of the left thumb as a residual of the service-connected DeQuervain's tenosynovitis of the left wrist are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310; Diagnostic Code 5228. 6. Prior to February 7, 2021, the criteria for a rating in excess of 10 percent for bilateral pes planus were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 55276. 7. From February 7, 2021, the criteria for a rating of 10 percent but no higher, for bilateral pes planus are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5269. 8. The criteria for entitlement to an initial rating in excess of 10 percent disabling for cranial nerve V sensory dysfunction, status post mandibular branch injury have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.124, 4.124a, Diagnostic Code 8305. 9. The criteria for entitlement to an initial rating in excess of 50 percent disabling for posttraumatic stress disorder (PTSD) have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from November 1993 to November 2013. Increased Rating Claims Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38U.S.C. §1155; 38C.F.R. §§3.321(a), 4.1. 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. 38C.F.R. §4.7. In initial rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating musculoskeletal disabilities based on limitation of motion, the Veteran is entitled to at least the minimum compensable evaluation if motion is accompanied by pain. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Additionally, pain is also relevant to assignment of a rating in excess of the minimum compensable rating, but only if that pain results in demonstrated functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, (2011); see 38 C.F.R. §§ 4.40, 4.45. Functional impairment as contemplated by 38 C.F.R. §§ 4.40 and 4.45 includes 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, 25 Vet. App. at 44. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. See generally Mitchell, 25 Vet. App. at 32. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). 1. Entitlement to an initial disability evaluation rating in excess of 10 percent for degenerative arthritis of the thoracolumbar spine Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine ("general rating formula"). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Effective February 7, 2021, the spine regulations were amended to state that Diagnostic Code 5243 governing intervertebral disc syndrome should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that Diagnostic Code 5242 should apply to all other disc diagnoses. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective February 7, 2021). The Board notes that this change does not impact the evaluation in this case as the Veteran does not have any evidence of intervertebral disc syndrome or incapacitating episodes that would warrant a compensable rating under Diagnostic Code 5243. According to the general rating formula, a 10 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is to be assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242 for degenerative arthritis of the spine. The Veteran was afforded a VA examination in January 2020. The examiner noted a diagnosis of degenerative arthritis of the thoracolumbar spine. The Veteran reported persistent worsening of pain and tightness of the lower back since her in-service injury. She denied flare-ups and functional impairment. Range of motion testing showed normal range with pain on forward flexion that didn't result in functional loss. There was no evidence of pain with weight bearing but the Veteran had mild paraspinal muscle tenderness. The Veteran was able to perform repetitive use testing with no additional limitations. The Veteran had muscle spasms not resulting in abnormal gait or spinal contour. Muscle strength was normal with no atrophy. Reflex and sensory examinations were normal and straight leg raising test was negative with no radiculopathies. The Veteran did not have intervertebral disc syndrome (IVDS) or episodes requiring bed rest. DeLuca factors, other than pain on motion, were not present. Upon review of the record, the Board finds that a rating in excess of 10 percent is not warranted. None of the above evidence reflects forward flexion limited to greater than 30 degrees but not greater than 60 degrees or combined range of motion not greater than 120 degrees, on repetitive use. Nor does the above evidence reflect the presence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The evidence also does not demonstrate that the Veteran experiences incapacitating episodes requiring bed rest, and the Veteran did not have any neurological deficits. Passive range of motion testing was not performed as it was not feasible or safe. Lay and medical evidence demonstrate that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the current 10 percent disability rating. Therefore, the Veteran's claim for an increased rating is denied. 2. Entitlement to an initial rating in excess of 10 percent disabling for DeQuervain's tenosynovitis of the right wrist 3. Entitlement to an initial rating in excess of 10 percent disabling for DeQuervain's tenosynovitis of the left wrist The Veteran's bilateral wrist disorders are currently assigned bilateral 10 percent ratings under Diagnostic Code 5215. The right wrist is her dominant wrist. In order to warrant a higher disability rating, the evidence must show favorable ankylosis between 20 to 30 degrees (30 percent under DC 5214); palmar flexion limited in line with the forearm (10 percent under DC 5215); or dorsiflexion limited to less than 15 degrees (10 percent under DC 5215). Pursuant to the November 2019 Board decision, a November 2019 rating decision granted 10 percent ratings for the Veteran's right and left wrist disorders. The Veteran was afforded a VA wrists examination in January 2020. The examiner noted diagnoses of Dequervain's tenosynovitis of the right and left wrists. The Veteran reported pain, fatigability, and incoordination of the bilateral thumbs. She stated that her thumbs become painful and "give out" after any activity that requires a prolonged grip. Objective examination showed normal range of motion with pain on palmer flexion. There was no crepitus. The Veteran was able to perform repetitive use testing with no additional limitations. Muscle strength testing was normal. The Veteran had functional loss due to pain, fatigue, and incoordination. Upon review of the record, the Board finds the preponderance of the evidence is against assigning evaluations in excess of 10 percent at any point during the period of the claim. Range of motion testing performed during the VA examination revealed normal range of motion and no additional limitation of motion with repetitive motion. The Veteran has not claimed nor has the evidence shown either wrist to be ankylosed at any angle. Therefore, the medical evidence does not warrant a higher rating under Diagnostic Code 5214 for ankylosis. Further, the Board has considered the Veteran's lay contentions and finds the lay statements are competent insofar as they report observable symptoms, such as pain. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, to the extent the Veteran asserts that her current disabilities entitle her to higher disability ratings, such statements are inconsistent with the medical evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Upon careful consideration of the evidence, higher ratings in excess of those assigned are not warranted and the Veteran's claims are denied. 4. Entitlement to a separate rating for service connection for painful limitation of motion of the right thumb as residual of service-connected DeQuervain's tenosynovitis of the right wrist 5. Entitlement to a separate rating for service connection for painful limitation of motion of the left thumb as residual of service-connected DeQuervain's tenosynovitis of the left wrist The Veteran's representative argues and the Board concludes that the Veteran is entitled to separate evaluations for painful limitation of motion of her right and left thumbs under Diagnostic Code 5228. The January 2020 VA examination showed incoordination of the bilateral thumbs, as well as difficulty with grip, fatigue, and pain with flexion. The Veteran is entitled to separate ratings for such impairment under Diagnostic Code 5228. 38 C.F.R. §§ 4.59, 4.71a. The rating activity will be responsible for assigning the appropriate level of disability and effective date in the first instance as these are downstream elements of the claim. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). 6. Entitlement to an initial rating in excess of 10 percent disabling for right plantar fasciitis The Veteran's pes planus is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Diagnostic Code 5276 criteria are not conjunctive. The Court has indicated that § 4.21 applies are those in which the diagnostic criteria are not clearly joined in the conjunctive. Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007); see also Dyess v. Derwinski, 1 Vet. App. 448 (1991) (holding that 38 C.F.R. § 4.21 specifically applies to Diagnostic Code 5276). Notably, prior to February 7, 2021, the rating schedule did not contain a diagnostic code for plantar fasciitis. Rather, it was typically rated by analogy to pes planus. Since that time, however, the rating schedule has been amended to add Diagnostic Code 5269. Under that code, when there is unilateral involvement, with no relief from both non-surgical and surgical treatment, a 20 percent rating is warranted. Otherwise, a 10 percent rating is warranted. This code may not be applied prior to the effective date of the regulation amended the criteria, and the Board will apply the version of the criteria most favorable to the Veteran. The Veteran was afforded a VA examination of her right foot in January 2020. The examiner diagnosed right foot plantar fasciitis. She reported right plantar foot pain. The pain is in her arch and worsens with prolonged standing or walking, limiting her ability to do so. Objective examination showed the Veteran had pain accentuated on use of the right foot. There was no pain with manipulation, swelling, characteristic calluses, extreme tenderness, decreased longitudinal arch, marked deformity, marked pronation, inward bowing, inward displacement, Morton's neuroma, hammertoe, hallux valgus, hallux rigidus, pes cavus, or other foot injuries not previously described. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent. Although there was pain on manipulation and pain accentuated on use, there was no evidence of marked abduction, marked pronation, swelling, callosities, extreme tenderness of plantar surfaces of the feet, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, including his statements that the arch supports do not alleviate pain. However, the currently assigned ratings consider both the Veteran's objective and lay symptoms. The evidence does not support a finding that the severity of the Veteran's right foot plantar fasciitis is moderately-severe in nature at any point on appeal. Ultimately, the rating of 10 percent for pes planus or 10 percent rating for unilateral plantar fasciitis properly compensates the Veteran for any functional impairment. As noted above, prior to February 2021, there was no diagnostic code specific to plantar fasciitis, so it was rated as pes planus under Diagnostic Code 5276. However, due to regulatory changes effective February 7, 2021, plantar fasciitis is to be rated under Diagnostic Code 5269. It is permissible to switch Diagnostic Codes to reflect more accurately a claimant's current symptoms. Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the Diagnostic Code associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). Because the Board is granting a rating of 10 percent under Diagnostic Code 5269, the Veteran is more appropriately rated under Diagnostic Code 5269 effective February 7, 2021 and not under Diagnostic Code 5276 with no prejudice to the Veteran and no impermissible reduction due to the Board's action. Further, the Board has considered the applicability of other foot diagnostic codes and finds that Diagnostic Codes 5277 (weak foot), 5278 (claw foot), 5279 (metatarsalgia), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), and 5283 (malunion or nonunion of the tarsal or metatarsal bones) do not apply. This is because the Veteran's service-connected plantar fasciitis and associated symptoms do not overlap with any of these foot disorders. 7. Entitlement to an initial rating in excess of 10 percent disabling for cranial nerve V sensory dysfunction, status post mandibular branch injury The Veteran's cranial nerve V sensory dysfunction, status post mandibular branch injury is rated under Diagnostic Code 8305, which addresses diseases of the fifth (trigeminal) cranial nerve, specifically pertaining to neuritis of that nerve. A 10 percent rating is assigned for incomplete, moderate paralysis of the nerve. A 30 percent rating is given for incomplete, severe paralysis of the nerve. A 50 percent rating is assigned for complete paralysis of the nerve. See 38 C.F.R. § 4.124a, Diagnostic Code 8205, 8305, 8405. The words "mild," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The Veteran was afforded a VA cranial nerves examination in January 2020. The examiner noted a diagnosis of cranial nerve V sensory dysfunction, status post mandibular branch injury. The Veteran had moderate numbness of the left upper face. Muscle strength testing was normal. A sensory examination showed decreased sensation to the left lower face. The examiner indicated that she had moderate incomplete paralysis of the left cranial nerve V. This disorder did not impact the Veteran's ability to work. Based on the evidence of record, the Board finds that the Veteran's disability more nearly approximate symptoms manifested by incomplete, moderate paralysis of the nerve. As noted above, the VA examiner found that the Veteran's left side was manifested by moderate numbness. Although muscle strength testing was normal, the examiner noted decreased sensation in the Veteran's left lower face. The Board has considered the Veteran's statements but finds that they do not show evidence supporting a higher rating under the schedular criteria. Therefore, based on the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted and the Veteran's claim for an increased evaluation is denied. 6. Entitlement to an initial rating in excess of 50 percent disabling for posttraumatic stress disorder (PTSD) In an August 2020 rating decision, the Veteran's PTSD evaluation was increased to 50 percent, effective December 1, 2013. All psychiatric disabilities are evaluated under a General Rating Formula for Mental Disorders ("General Rating Formula"). Under the General Rating Formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less often, chronic sleep impairment, and mild memory loss (i.e. forgetting names, directions, or recent events). A 50 percent rating is warranted under the General Rating Formula for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks occurring more than once a week, difficulty in understanding complex commands, impairment of short-term memory (i.e. retention of only highly learned material or forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted under the General Rating Formula for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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 under the General Rating Formula 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 the ability to maintain minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. The symptoms listed under the rating criteria are meant to be examples of symptoms that would warrant the rating, but they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran was afforded a VA PTSD examination in January 2020. The examiner noted a diagnosis of PTSD. The Veteran reported that she had a sleep delay nightly due to worrying and racing thoughts. Her symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Regarding occupational impairment, the Veteran left multiple jobs due to her anxiety from being criticized for her work and currently volunteers but is unemployed. Regarding social impairment, the Veteran stated that she stays away from social settings if there are males present. She is concerned about panic attacks around others. She adopted her great-nephew and was caring for two of his siblings until they were removed from her home due to hoarding concerns. She has friends from her church. The examiner characterized her PTSD as manifesting occupational and social impairment with reduced reliability and productivity. The examiner remarked that based on the examination, the Veteran still met DSM-V diagnostic criteria for her PTSD. She was also administered a test test which is a widely accepted instrument to assess PTSD and other Mental Health diagnoses. It has built in validity scales to detect a response style of exaggeration or skewed symptom presentation. Examinees are specifically instructed to be honest and open in their test taking approach as this test is designed to detect if a respondent is trying to misrepresent themselves (i.e., "faking good or bad"). It should be noted that the Veteran's test results were not valid and indicate a statistically significant exaggeration of symptoms well beyond the 99th Percentile. Consequently, the test results could not be used support any diagnostic conclusion in the examination report, but do indicate the possibility of symptom exaggeration. Also, there are no Mental Health treatment reports available because the Veteran had not engaged in any treatment since the last examination, by her choice. As a result, the opinions in the examination report were based less on her direct report and more on observations and clinical history. Despite the above, the examiner noted level of occupational and social functioning does appear worse than the last examination, in the opinion of the examiner clinician. Her anxiety symptoms and guarded approach were seen as causing mood shifts and interpersonal problems. These problems appeared to include her difficulty connecting with people, maintaining a household with more than one child and functioning adequately around people at work. The Veteran had some signs of increased depression since the last examination, likely related to the removal of the two children from her home, but these were not seen as enough to constitute an additional diagnosis. Also, the Veteran had some signs of an Axis II diagnosis but again not enough to meet criteria for a diagnosis, but they may affect her in close relationships. The Veteran was advised to seek Mental Health treatment of therapy to begin with and meds if recommended. Upon review of the record, the Board finds that a rating in excess of the 50 percent currently assigned is not warranted. The Veteran's symptoms included depressed mood, anxiety, sleep impairment, disturbance of motivation and mood, and difficulty in adapting to stressful circumstances. While the Veteran did experience some social isolation and occupational impairment, including inability to establish and maintain effective relationships, the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. The Veteran continued to care for a child and have personal relationships. The Veteran's mental status examinations were normal; and she denied suicidal or homicidal thoughts. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. The preponderance of the evidence is against finding that a higher, 70 percent rating is warranted and the Veteran's claim for an increased rating is denied. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shana Z. Siesser, 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.