Citation Nr: 21071836 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 19-33 115 DATE: December 1, 2021 ORDER Service connection for an acquired psychiatric disorder, separate and distinct from service-connected unspecified anxiety disorder, now characterized as posttraumatic stress disorder (PTSD), is denied. Prior to September 13, 2017, an initial rating in excess of 30 percent, but no higher, for service-connected unspecified anxiety disorder, now characterized as PTSD, is granted, subject to the laws and regulations governing the payment of monetary benefits. As of September 13, 2017, an initial rating in excess of 50 percent for service-connected unspecified anxiety disorder, now characterized as PTSD, is denied. FINDINGS OF FACT 1. At no time during the pendency of the claim does the Veteran have a current disability of an acquired psychiatric disorder, separate and distinct from his service-connected unspecified anxiety disorder, now characterized as PTSD, and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. 2. Prior to September 13, 2017, the Veteran's service-connected unspecified anxiety disorder, now characterized as PTSD, was manifested by psychiatric symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 3. As of September 13, 2017, the Veteran's service-connected unspecified anxiety disorder, now characterized as PTSD, is manifested by psychiatric symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas or total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, separate and distinct from service-connected unspecified anxiety disorder, now characterized as PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. Prior to September 13, 2017, the criteria for an initial rating of 30 percent, but no higher, for unspecified anxiety disorder, now characterized as PTSD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9413. 3. As of September 13, 2017, the criteria for an initial rating in excess of 50 percent for unspecified anxiety disorder, now characterized as PTSD, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1955 to June 1955. This matter comes to the Board of Veteran's Appeals (Board) on appeal from a rating decision issued in August 2016 by a Department of Veterans Affairs (VA) Regional Office. In March 2021, the Veteran and his son testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In July 2021, the Board remanded the issues on appeal for additional development and the case now returns for further appellate review. By way of background, the Veteran's service treatment records (STRs) reflect that, in February 1955, he was hospitalized as a result of inhaling chlorine gas in the gas chamber and, in April 1955, he reported shortness of breath, which was attributed to anxiety. Post-service VA treatment records dated in February 2014 reflect that the Veteran did not meet the full criteria for a diagnosis of PTSD or depressive disorder; however, he was diagnosed with specified trauma- and stressor-related disorder and other specified depressive disorder related to his in-service experience in the gas chamber. At such time, it was noted that he had impaired sleep, fair concentration, recent forgetfulness with difficulty remembering names, waking up at night gasping for breath, avoidance, inability to tolerate certain odors, approximately three to four panic attacks over the past two years, and issues with anger. However, the Veteran having a good appetite and fairly good enjoyment of things, such as listening to music and being around people. At a July 2016 VA examination, it was determined that the Veteran only had a diagnosis of unspecified anxiety disorder, which was currently service-connected. In this regard, the examiner found that such disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. At such time, the Veteran reported that he had a great relationship with his family members. In this regard, he indicated that he had been married to his spouse since 1955, had three sons, four grandchildren, and two great grandchildren. The Veteran further reported that he previously worked in various capacities prior to retiring; however, he continued to drive his spouse and friends to get groceries and go to doctor appointments. The Veteran's symptoms were noted to only include anxiety, and his mental status examination was normal with the exception of an anxious mood. In his October 2016 notice of disagreement, the Veteran stated that he could have suicidal tendencies because when he had a panic attack, he was not in control of himself and he could not remember what was happening. In May 2017, he was again diagnosed with specified trauma- and stressor-related disorder with panic attacks, and reported that he continued to have anxiety, difficulty sleeping, an adverse reaction to unusual or bad odors, panic attacks that occurred three to four times a year, and prior anger issues, which resulted in fights 10 to 15 years previously. He reported good energy and appetite until recent gastrointestinal surgery, and denied depressive symptoms, and suicidal thoughts or a desire to die. Following objective testing, the Veteran was found to have dementia. His treatment provider ultimately noted symptoms of intrusion, avoidance, arousal, and anxiety during brief periods of time around panic attacks, which reportedly occurred three to four times per year. At a September 2017 VA examination, it was determined that the Veteran only had a diagnosis of unspecified anxiety disorder, which is currently service-connected. In this regard, the examiner found that such disability resulted in 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. At such time, the Veteran again reported that his married with three children and was retired. He further indicated that got along well with others, but isolates himself due to his anxiety. The Veteran's symptoms were noted to include anxiety, panic attacks more than once a week, and difficulty in adapting to stressful circumstances, including in a work or work-like setting. Mental status examination was normal with the exception of appearing dysphoric and anxious. The Veteran was again diagnosed with specified trauma- and stressor-related disorder with panic attacks in September 2018, November 2018, and July 2019, and recurrent depressive disorder in July 2018. In September 2018 and November 2018, the Veteran endorsed continued symptoms of intrusion, avoidance, and some arousal symptoms; however, he did not meet the full diagnostic criteria for PTSD. At such time, he reported having panic attacks three to four times per year and felt anxious much of the time, but denied having depressive symptoms. At the March 2021 Board hearing, the Veteran and his son reported that he continued to have anxiety related to such in-service experience, and also experienced difficulty with concentration and memory, had an adverse reaction to smelling fuel or exhaust, and had depression. At an August 2021 VA examination, it was determined that the Veteran only had a diagnosis of PTSD, which the Agency of Original Jurisdiction (AOJ) noted was a recharacterization of his service-connected unspecified anxiety disorder. In this regard, the examiner found that such disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. At such time, the Veteran again reported that his married with three children and was retired. He also indicated that he experienced anxiety, panic, avoidance of crowded places, and intrusive memories and the examiner noted the presence of anxiety and depression on examination. Mental status examination was normal with the exception of tangential speech and an occasional inability to state his history. The examiner further stated that the Veteran did not have a separate diagnosis of a depressive disorder or specified trauma- and stressor-related disorder as his symptoms were included in the diagnosis of PTSD. Further, he indicated that, for the Veteran's diagnosis of unspecified anxiety disorder, such changed and he had a new and separate diagnosis of PTSD, which encompassed all of his psychiatric symptoms. 1. Entitlement to service connection for an acquired psychiatric disorder, separate and distinct from service-connected unspecified anxiety disorder, now characterized as PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). An award of service connection requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen, 7 Vet. App. 439; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability"). However, VA requires a diagnosis that conforms to the DSM-5 to compensate for a psychiatric disability, therefore constraining the application of Saunders in the context of claims for service connection for psychiatric disabilities. Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020); 38 C.F.R. § 4.125(a). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the United States Court of Appeals for Veterans Claims (Court) held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Based on the foregoing, the Board finds that at no time during the pendency of the claim does the Veteran have a current disability of an acquired psychiatric disorder, separate and distinct from his service-connected unspecified anxiety disorder, now characterized as PTSD, and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. In this regard, the Board notes that, while VA treatment records reflect diagnoses of specified trauma- and stressor-related disorder and depressive disorder, the August 2021 VA examiner found that the Veteran did not have separate diagnoses of such disorders as his symptoms were included in the diagnosis of PTSD. Further, he indicated that, in regard to the Veteran's service-connected diagnosis of unspecified anxiety disorder, such changed and he had a new and separate diagnosis of PTSD, which encompassed all of his psychiatric symptoms. Consequently, the totality of the Veteran's symptoms are encompassed in his current diagnosis of PTSD, which is service-connected, and he did not have a diagnosis of a separate and distinct acquired psychiatric disorder. The Board affords great probative weight to the August 2021 VA examiner's opinion as such considered all of the pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Conversely, the Board affords no probative weight to the Veteran's lay statements regarding the presence of an acquired psychiatric disorder other than his already service-connected PTSD as he, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis of such disorder involves a medical subject concerning an internal psychiatric process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board affords the Veteran's statements as to a current diagnosis of an acquired psychiatric disorder other than his already service-connected PTSD no probative weight. Consequently, the Board finds that at no time during the pendency of the claim does the Veteran have a current disability of an acquired psychiatric disorder, separate and distinct from his service-connected unspecified anxiety disorder, now characterized as PTSD, and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. Thus, service connection for an acquired psychiatric disorder, separate and distinct from service-connected unspecified anxiety disorder, now characterized as PTSD, is not warranted. Watson, supra; Brammer, supra; Rabideau, supra. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claim for service connection for acquired psychiatric disorder, separate and distinct from service-connected unspecified anxiety disorder, now characterized as PTSD. As such, that doctrine is not applicable in the instant appeal and such claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 2. Entitlement to an initial rating in excess of 10 percent prior to September 13, 2017, and in excess of 50 percent thereafter for unspecified anxiety disorder, now characterized as PTSD. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran's service-connected unspecified anxiety disorder, now characterized as PTSD, is evaluated as 10 percent disabling as of December 30, 2015, the date of service connection, and 50 percent disabling as of September 13, 2017, under Diagnostic Code 9413, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. In this regard, such provides a 10 percent rating when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is 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. A 70 percent rating is warranted when there is 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The United States Court of Appeals for the Federal Circuit has held that the 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, 116-117 (Fed. Cir. 2013). 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 117-118; 38 C.F.R. § 4.130. Further, 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). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. The Board notes that the DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug. 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. Golden v. Shulkin, 29 Vet. App. 221 (2018). Based on the foregoing, the Board notes that the Veteran's social and occupational history remained the same throughout the entire appeal period. In this regard, he has reported that he has a great relationship with his family members. Specifically, he indicated that he had been married to his spouse since 1955, had three sons, four grandchildren, and two great grandchildren. The Veteran further reported that he previously worked in various capacities prior to retiring; however, he continued to drive his spouse and friends to get groceries and go to doctor appointments. However, based on the nature, frequency, duration, and severity of the Veteran's psychiatric symptomatology, the Board finds that the AOJ appropriately awarded staged ratings for such disability during the appeal period. The Board further finds that, prior to September 13, 2017, the Veteran's service-connected unspecified anxiety disorder, now characterized as PTSD, was manifested by psychiatric symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, thus warranting an initial rating of 30 percent for such period. However, as such does not result in more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment, an initial rating in excess of 30 percent prior to September 13, 2017, is not warranted. In this regard, the record reflects that, during such period, the Veteran's psychiatric disability was manifested by anxiety, impaired sleep, intrusion, avoidance, arousal, inability to tolerate certain odors, approximately three to four panic attacks a year, and prior issues with anger. Further, while the Veteran was noted to have forgetfulness with difficulty remembering names, he also had a recent diagnosis of dementia, which is not service-connected. He also had a good appetite and fairly good enjoyment of things, such as listening to music and being around people, and denied depressive symptoms and suicidal thoughts or a desire to die. In this regard, the Board notes that, while the Veteran reported that he could have suicidal tendencies because when he had a panic attack, he was not in control of himself and he could not remember what was happening in October 2016, the record does not show that he actually had suicidal ideation. Furthermore, while the July 2016 VA examiner found that the Veteran's psychiatric disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication, which is commensurate with a 10 percent rating under the General Rating Formula, the Board finds that the totality of the Veteran's aforementioned symptoms more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, thus warranting a 30 percent rating. However, the totality of the Veteran's psychiatric symptomatology is fully contemplated by the 30 percent rating awarded herein, and there is no evidence that his psychiatric disability results in 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Moreover, the Veteran maintains a close relationship with spouse and sons, enjoys activities such as listening to music, and remains engaged as a driver for his spouse and friends to get groceries and go to doctors' appointments. Thus, the evidence does not show that his psychiatric disability results in in a greater degree of impairment in occupational and social functioning than as contemplated by the currently assigned 30 percent rating. Consequently, higher rating is not warranted prior to September 13, 2017. Furthermore, the Board finds that, as of September 13, 2017, the Veteran's service-connected unspecified anxiety disorder, now characterized as PTSD, is manifested by psychiatric symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas or total occupational and social impairment. Thus, an initial rating in excess of 50 percent for such period is not warranted. In this regard, the record reflects that, during such period, the Veteran's psychiatric disability is manifested by anxiety, panic attacks more than once a week, difficulty with concentration and memory, an adverse reaction to smelling fuel or exhaust, depression, avoidance of crowded places, isolation, intrusive memories, and difficulty in adapting to stressful circumstances, including in a work or work-like setting, with dysphoria, anxiety, tangential speech, and an occasional inability to state his history on mental status examination. In this regard, while the September 2017 VA examiner found that the Veteran's psychiatric disability resulted in difficulty in adapting to stressful circumstances, including in a work or work-like setting, which is indicative of a 70 percent rating under the General Rating Formula, the remainder of the record is void of any symptoms indicative of such a rating. Furthermore, the Board finds that the nature, frequency, duration, and severity of such symptomatology does not more nearly approximate occupational and social impairment in most areas. In this regard, the Board again notes that the Veteran maintains a close relationship with spouse and sons, enjoys activities such as listening to music, and remains engaged as a driver for his spouse and friends to get groceries and go to doctors' appointments. Furthermore, upon consideration of the totality of the Veteran's psychiatric symptomatology, the September 2017 VA examiner found that his psychiatric disability resulted in 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, which is commensurate with a 30 percent rating under the General Rating Formula. Similarly, the August 2021 VA examiner found that such disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication, which is commensurate with a 10 percent rating under the General Rating Formula. Consequently, based on the foregoing, the Board finds that an initial rating in excess of 50 percent as of September 13, 2017, is not warranted. The Board has considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected psychiatric disability; however, the Board finds that his symptomatology had been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching the foregoing determination, the Board has applied the benefit of the doubt doctrine and resolved all doubt in the Veteran's favor, which has resulted in a partial award of an initial 30 percent rating, but no higher, for the Veteran's psychiatric disability prior to September 13, 2017. However, insofar as the Board has denied an initial rating in excess of 30 percent prior to September 13, 2017, and in excess of 50 percent thereafter for the Veteran's unspecified anxiety disorder, now characterized as PTSD, the preponderance of the evidence is against such aspects of the Veteran's claim. Therefore, the benefit of the doubt doctrine is not applicable in such regard and his initial rating claim must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Spielmann, Jill F. 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.