Citation Nr: 21005787 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 18-28 308A DATE: February 2, 2021 ORDER Service connection for a left shoulder disability, to include arthritis, is denied. Service connection for a left hip disability, to include arthritis, is denied. Service connection for a right hip disability, status post hip replacement, is denied. Service connection for a low back disability, to include stiffness, painful spinal canal stenosis, and bilateral foraminal stenosis, is denied. Service connection for a skin disability, to include recurrent boils on ears, is denied. An initial rating of 50 percent for anxiety disorder for the period prior to November 4, 2020, is granted. A rating in excess of 70 percent for anxiety disorder for the period from November 4, 2020, is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period prior to November 4, 2020, is remanded. FINDINGS OF FACT 1. The Veteran has a diagnosis of left shoulder bursitis, which did not manifest in active service and is not otherwise etiologically related to such service. 2. The Veteran has a diagnosis of left hip degenerative arthritis, which did not manifest in active service and is not otherwise etiologically related to such service. 3. The Veteran has a diagnosis of status post right hip replacement, which did not manifest in active service and is not otherwise etiologically related to such service. 4. The Veteran has a diagnosis of low back degenerative arthritis, which did not manifest in active service and is not otherwise etiologically related to such service. 5. The probative evidence of record does not show that the Veteran has a current diagnosis of skin condition. 6. For the period of appeal prior to November 4, 2020, the evidence is in equipoise on whether the Veteran’s anxiety disorder was productive of a disability picture that more nearly approximated that of occupational and social impairment with reduced reliability and productivity. 7. For the period of appeal from November 4, 2020, the evidence is in equipoise on whether the Veteran’s anxiety disorder is productive of a disability picture that more nearly approximates that of occupational and a social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a skin disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303 6. For the period of appeal prior to November 4, 2020, the criteria for an initial 50 percent rating for anxiety disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9413. 7. For the period of appeal from November 4, 2020, the criteria for a rating in excess of 70 percent for anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from March 1974 to March 1976. A Board hearing was held in July 2019 before the undersigned at the central office in Washington, D.C., and the transcript is of record. The Board remanded the issues in October 2019 and April 2020 for further development, including obtaining outstanding treatment records and scheduling the Veteran for relevant VA examinations. VA treatment records and private treatment records have subsequently been associated with the claims file, and the Veteran had a series of VA examinations in September 2020. The Board therefore finds there has been substantial compliance with the remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or an injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability also may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disability or if it is aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439 (1995). Certain disease, including arthritis, are listed among the “chronic diseases” under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). 1. Service connection for a left shoulder disability. 2. Service connection for a left hip disability. 3. Service connection for a right hip disability. 4. Service connection for a low back disability. The Veteran contends that his claimed left shoulder, bilateral hip, and low back conditions are due to sleeping on a deflated air mattress on a cold ground while in Germany in 1975. His left shoulder condition is also due to carrying an M-60 machine gun. See the March 2017 statement, June 2018 VA Form 9, July 2019 Board hearing transcript. The Veteran has current diagnoses of left shoulder strain, status post right hip replacement, bilateral hip degenerative arthritis, and lumbar spine degenerative arthritis. Thus, the current disability requirement for service connection for left shoulder, bilateral hip, and low back disabilities is satisfied. The question for the Board is whether the Veteran’s current left shoulder, bilateral hip, and low back diagnoses either began during active service, or are etiologically related to an in-service disease or injury. The Board finds that the probative evidence establishes that the current left shoulder, bilateral hip, and low back diagnoses are not etiologically related to the Veteran’s active service. Service treatment records (STRs) are silent for mention of any complaints, diagnoses, or treatment of any left shoulder, left hip, right hip, or back problems. In a February 1974 enlistment examination, the Veteran’s upper extremities, lower extremities, and spine were noted to be clinically normal. In a February 1976 service separation examination, the Veteran’s upper extremities, lower extremities, and spine were again noted to be clinically normal. Post-service treatment records indicate that in an October 1988 VA examination, the Veteran was noted to have had an in-service injury to the left knee, which had healed well without residuals. The examination report is silent for mention of any other musculoskeletal complaints or diagnosis. VA treatment records indicate that in a May 2009 initial visit, the Veteran reported having chronic back stiffness. In February 2012, the Veteran reported having chronic right shoulder pain, and did not mention his left shoulder. In a December 2013 evaluation, the Veteran indicated that he thought he did something to his left shoulder, which hurt but did not cause difficulty in moving. He was assessed as having bursitis, given Indocin, and advised to cut down on his alcohol use. In August 2015, the Veteran reported having right hip pain. X-rays showed arthritic changes in the right hip joint and low back. An MRI showed advanced osteoarthritis if the right hip with nonspecific, severe, extensive bone marrow edema. The MRI als showed moderate spinal stenosis at L3-4 and L5-S1 and degenerative joint disease (DJD) changes. In October 2016, the Veteran had a right hip replacement surgery. The Veteran was afforded a series of VA examinations in September 2020. In the left shoulder examination, the Veteran reported that he began having pain and a decreased range of motion seven years ago. He denied having any left shoulder injury or pain that started in service. The examiner noted that the Veteran had been diagnosed with left shoulder bursitis in 2013. On examination, the left shoulder had a decreased range of motion with pain noted to cause problems with lifting and carrying. There was also tenderness to palpation and evidence of pain with weight bearing. In the hip examination, the Veteran reported having right hip pain that started in 2014 and denied injuring the hip. His left hip pain started after a right hip replacement in 2016. His right hip pain had improved, and his left hip pain had remained the same. The examiner noted that the Veteran had bilateral degenerative arthritis and was status post right hip joint replacement. On examination, there was no limitation in ranges of motion or pain on palpation in either hip. The left hip showed objective evidence of pain with abduction, adduction, external rotation, and internal rotation. In the back examination, the Veteran reported having low back pain that started in the 1980s. He denied having back pain in service, and indicated that the back pain improved when he had right hip surgery in 2016. He currently had no symptoms. The examiner noted that degenerative arthritis had been diagnosed in 2015. On examination, there was no limitation in ranges of motion, pain, or pain on palpation. The examiner concluded that the left shoulder, left hip, right hip, and low back diagnoses were each less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that bursitis is an overuse injury and degenerative arthritis, also known as osteoarthritis, was a breakdown of the cartilage of the joints and discs. The Veteran’s left shoulder, hips, and low back conditions were diagnosed in 2013 (left shoulder), 2015 (back and right hip), 2016 (left hip). STRs were silent for evidence of a left shoulder, left hip, right hip, or back injury that occurred in service. Osteoarthritis occurred as a result of wear and tear of the joint that occurred over time and with age, and is most common among individuals 50 years of age and older. Finally, the examiner also noted there was no evidence of hip pain as a result of a cold weather injury. The Board finds that the VA examiner’s opinions to be competent and credible, and as such, entitled to significant probative weight. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinions were rendered after reviewing the Veteran’s STRs and other medical records, soliciting a medical history from the Veteran, and conducting a physical examination and clinical testing of the Veteran. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner’s access to the claims folder and the Veteran’s history, and the thoroughness and detail of the opinion). The VA examiner provided facts and rationale on which she based her opinion, including expressly discussing STRs and post-service medical records. Furthermore, neither the Veteran nor his representative has produced a medical opinion to contradict the conclusion of the VA examiner. As such, there is no competent medical evidence that relates the current left shoulder, bilateral hip, or low back diagnoses to the Veteran’s military service. The Board also finds that although the Veteran can describe observable symptoms including pain, his statements cannot be used to determine whether a low back diagnosis is related service or to an in-service injury. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There is no evidence that the Veteran has the medical education and training required to make competent clinical diagnosis, or to attribute such a diagnosis to specific events or injuries. Moreover, the Veteran has been inconsistent in his statements. Specifically, he has claimed that the left shoulder, hips, and back conditions are due to sleeping on a deflated air mattress on a cold ground in service, and also stated in the 2020 VA examinations that these conditions started after he separated from service. As such, the Board finds the Veteran’s statements probative with regard to establishing his current symptoms, but finds little probative value with regard to establishing service connection. In any case, their probative value is outweighed by the probative value assigned to an evaluation conducted by a person who has expertise and training pertinent to musculoskeletal diagnoses. Finally, the earliest evidence of complaints or treatment for any of these conditions was in 2009, which was 33 years after the Veteran’s separation from service. This lengthy period of time without diagnosis or treatment weighs against the finding that any current left shoulder, left hip, right hip, or low back diagnosis has existed since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As noted above, STRs do not document any left shoulder, hip, or low back complaints; there is no medical evidence showing relevant symptoms or a diagnosis within one year from service separation; and the competent and credible evidence does not establish chronic and continuous symptoms of any left shoulder, hip, or low back disability. As such, service connection on a presumptive basis under 38 C.F.R. § 3.303 (a) or (b) is not warranted. In sum, the weight of the competent and credible evidence of record weighs against the claims for service connection for a left shoulder, left hip, right hip, and a low back disability. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Service connection for a skin disability. The Veteran contends that he has boils on his ears that are due to chronic sinusitis and tonsillitis. See the March 2017 statement, June 2018 VA Form 9, July 2019 Board hearing transcript. The Board finds that the Veteran does not have a diagnosed skin disability, to include boils on the ears. The Veteran had a VA skin diseases examination in September 2020. He reported that he had boils on his ears that started 30 years ago. Most recently, he had a furuncle (boil) removed two years ago. The Veteran denied having any boils on his ears in service; however, he did have sinus infections in service. The examiner concluded that the Veteran did not have any current skin conditions. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, and that a furuncle (boil) was not a symptom of sinusitis or medically related to sinusitis. VA treatment records dated during the period of appeal are silent for mention of any complaints, diagnosis, or treatment for any skin condition, including recurrent boils on the ears. In sum, the Board finds that the Veteran does not have current skin diagnosis and has not had a relevant diagnosis at any time during the pendency of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Board acknowledges that the Veteran was noted to have a three-day rash on his right ear, face, and neck in August 2009, and a rash on his arm in November 2009 that was noted to be most likely contact dermatitis from weeds or poison ivy. However, these skin diagnoses in 2009 were more than seven years prior to the date that the Veteran filed his claim for service connection for a skin disability. The Veteran contends that service connection is warranted for a skin disability, but the Board cannot rely on his assertions regarding medical diagnoses. The issue is medically complex, as it requires specialized medical education and knowledge of skin, the integumentary system, and symptoms of sinusitis. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, which notes that the Veteran does not have a skin diagnosis. Without competent evidence of a diagnosed disorder, service connection for a skin disability cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“In the absence of proof of a present disability, there can be no valid claim.”); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability). Increased Rating 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 the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. 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. 6. – 7. Increased ratings for anxiety disorder. The Veteran’s anxiety disorder was assigned an initial 30 percent rating effective January 19, 2017, under Diagnostic Code 9413. A 70 percent rating was assigned effective November 4, 2020. The rating criteria for rating mental disorders, including major depressive disorder, reads as follows: a 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. A 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. A 30 percent rating requires 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). Id. The Board notes that the DSM-5 states that it was recommended that the use of Global Assessment of Functioning (GAF) scores be dropped for several reasons, including their conceptual lack of clarity and questionable psychometrics in routine practice. The Board recognizes the Court’s holding in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) regarding the importance of GAF scores; however, as the medical community has determined that GAF scores are an unreliable measure of a psychiatric disability, the Board will not afford any GAF scores mentioned in the record any probative value in cases where the DSM-5 applies. See also Golden v. Shulkin, No. 16-1208 (U.S. Vet. App. February 23, 2018) (finding that the Board provided an inadequate statement of its reasons or bases for relying on GAF scores in its decision when the appeal was certified after August 4, 2014, and the DSM-5 applied to the claim). In this case, the Veteran’s appeal was certified to the Board in March 2019. As such, the DSM-5 applies and the Board will not afford GAF scores any probative value. Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Federal Circuit explained that the frequency, severity, and duration of the symptoms also played an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but 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, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443; see also Vazquez-Claudio, 713 F.3d at 117. Period of appeal prior to November 4, 2020 The Board finds that the evidence is in equipoise on whether a higher 50 percent rating is warranted for the period of appeal prior to November 4, 2020, under Diagnostic Code 9413. Private treatment records indicate that the Veteran began a substance use disorder treatment program in January 2017 and completed it in May 2017. In a May 2017 VA examination, the Veteran reported that he had been diagnosed with anxiety disorder last year and was receiving treating through VA. He also had a history of alcohol dependence and was participating in a civilian substance abuse treatment program. The Veteran stated that he had been in several long term relationships, but had never married. He had an adult daughter with whom he was not close, and a former girlfriend’s 18-year-old daughter considered him to be a father figure. The Veteran read the Bible and visited people when he had transportation. He had worked at a Goodyear tire store but felt over-worked by his manager. After leaving Goodyear because he almost drove a tow truck into his manager, he worked different jobs but could not keep them due to conflicts with supervisors and others. On examination, the Veteran’s appearance, dress, and grooming were unremarkable and age appropriate. His speech was normal, and he denied having suicidal or homicidal thoughts, hallucinations, or delusions. There were no signs of cognitive difficulty, memory was intact, and the Veteran was oriented to time and place. He required redirection at times due to tangentiality. There were no overt signs of excessive anxiety or hyperactivity, and judgement and insight appeared to be intact. The examiner indicated that the Veteran’s symptoms included anxiety, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. The examiner concluded that the Veteran’s symptoms caused occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. He was capable of managing his financial affairs. In November 2018, the Veteran was admitted to a VA intensive outpatient substance abuse treatment program (SATP), which included group and individual counseling sessions. He completed the first phase of the program in December 2018. He began attending the SATP aftercare program, phase two, in January 2019; and the recovery management group, phase three, four weeks later. The Veteran completed the program on February 21, 2019. In a March 2019 mental health evaluation, the Veteran reported that since participating in the SATP, he was drinking less and improving his coping skills. He denied having suicidal or homicidal thoughts. His symptoms included social anxiety and worrying thoughts. He had sleep difficulties that had improved somewhat since taking Neurontin. The Veteran enjoyed outdoor activities such as gardening, but had been more isolative over het past several months. In May 2019, the Veteran reported that he was continuing to learn some useful coping skills, including making plans to go fishing when he had time on his hands and wanted to drink. He indicated that he had taken paroxetine for a few weeks in March, which helped his mood, so he wanted to restart taking it. He also had difficulty sleeping, often awakening in a cold sweat. The Veteran testified in the July 2019 Board hearing that he had “very bad” symptoms, including not being able to sleep and having bad dreams, for which his doctor gave him gabapentin. He also had anxiety, which caused him to be quiet and avoid people. He did not like spending time around his family, including his brother and his niece, and thought “if you’re not with me, you’re against me” about people. The Veteran had not been able to hold a job for longer than two years since he separated from service. At a previous job at a factory, he had problems with his supervisor and a coworker. In August 2019, the Veteran indicated that he felt less depressed since starting back on paroxetine. In October 2019, the Veteran stated that he was enjoying life more and denied having thoughts of suicide. In February 2020, the Veteran reported that he was not drinking alcohol or smoking cigarettes; instead, he walked and read to occupy his mind. He had stopped taking paroxetine approximately three months prior and felt less depressed. The Veteran had a VA mental disorders examination in March 2020. He reported that he had depression most days, which was characterized by low mood, social isolation, irritability, guilt, and apathy, and he had a chronic lack of restorative sleep. He denied suicidal and homicidal thoughts, delusions and hallucinations, and a history of manic episodes. The Veteran indicated he spent most of his time at home and doing mechanic work, had a female friend, was unemployed, and was able to drive and engage independently in activities of daily living. On examination, the Veteran was casually dressed with fair hygiene. He was oriented and oriented with normal speech, although he was distractible, circumstantial, and tangential. Concentration and attention were moderately impaired, range of emotion was restricted, and psychomotor activity was agitated. The Veteran appeared genuine and forthcoming, without sign of perceptual disturbances. He denied any current suicidal ideation. The examiner indicated that the Veteran’s symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner concluded that the Veteran’s symptoms caused occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. He was capable of managing his financial affairs. In April 2020, the Veteran indicated that he was maintaining his sobriety and his mood, and denied having suicidal thoughts. In sum, for this period of appeal, the weight of the competent and credible evidence is in equipoise on whether the Veteran’s anxiety disorder warrants a 50 percent rating under Diagnostic Code 9413. The anxiety disorder manifested by symptoms including anxiety, tangential and circumstantial speech, sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. The Veteran had never been married, did not have close relationships with his children, and was not employed. Affording the Veteran the benefit of the doubt, such impairment warrants a 50 percent disability rating. Thus, the Board also finds that for this period of appeal, the evidence preponderates against the assignment of a 70 percent rating for the Veteran’s anxiety disorder. The Veteran’s anxiety symptoms did not more nearly approximate occupational and social impairment with deficiencies in most areas, which would warrant a 70 percent rating under Diagnostic Code 9413. The Veteran was not found to have suicidal ideation; obsessional rituals which interfere with routine activities; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships. Although the Veteran reported symptoms of disturbances of mood and difficulty with work and social relationships, the Board does not find this symptom to be of such frequency, severity, and duration that it results in occupational and social impairment with deficiencies in most areas to warrant a higher 70 percent evaluation at any point during the period of appeal. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (stating that use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating). As discussed above, the Veteran maintained some relationships, including having a female friend and visiting people when he had transportation, and doing activities such as mechanic work and reading. The Board also finds it significant that two VA examiners concluded that the Veteran’s anxiety disorder caused occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication, which warrants only a 30 percent rating. In short, the Board finds that a 50 percent rating prior to November 4, 2020, is warranted, but does not find that the Veteran’s symptoms were of such frequency, severity, and duration that they resulted in occupational and social impairment with deficiencies in most areas to warrant a higher 70 percent evaluation during this period of appeal. Period of appeal from November 4, 2020 The Board finds that the preponderance of the evidence is against the assignment of a higher 100 percent rating for the period of appeal from November 4, 2020, under Diagnostic Code 9413. The sole evidence for this period of appeal is a VA mental disorders examination that the Veteran had on November 4, 2020. He reported that he was taking Paxil, which helped with his sleep. He continued to be anxious and felt like he was on edge frequently. He endorsed racing thoughts that hindered his ability to focus and concentrate, felt defeated at times, and his appetite was inconsistent. The Veteran denied suicidal and homicidal ideation. He stated that he had two adult children, with whom he did not have relationships, and was not currently in a relationship. He was homeless and lived in his car most of the time. The Veteran had several close friends, attended a local church, and enjoyed fishing and playing pool. He had not worked full-time since 1998, which he asserted was due to his criminal record and his mental health issues. On examination, the Veteran was cooperative, alert, oriented, and well-groomed. His speech was circumstantial, without any delusions or hallucinations. His thoughts were scattered, judgement and insight were fair, and mood was fair with a flat affect. The examiner indicated that the Veteran’s mental health symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, circumstantial speech, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He was competent to manage his financial affairs. The examiner concluded that the Veteran’s symptoms caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. In sum, for this period of appeal, the evidence preponderates against the assignment of a 100 percent rating under Diagnostic Code 9413. Although it appears that the anxiety symptoms may have worsened during this period of appeal, including the Veteran becoming homeless, the symptoms do not more nearly approximate total occupational and social impairment, which would warrant a 100 percent rating under Diagnostic Code 9413. The Veteran has not been found to have symptoms of gross impairment in thought processes or communication; persistent delusions of hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Rather, the VA examiner indicated the Veteran was well-groomed, competent to manage his financial affairs, had several close friends, and enjoyed activities including playing pool and fishing. As such, the Board finds that the Veteran has not had any symptom with such frequency and severity to result in total occupational and social impairment during the period from November 4, 2020, and a rating in excess of 70 percent is denied. REASONS FOR REMAND 1. Entitlement to a TDIU prior to November 4, 2020, is remanded. The Veteran contends that he stopped working due at least in part to his service-connected anxiety disorder. See the May 2017 and November 2020 VA examination reports. The Board notes that the Veteran was granted entitlement to a TDIU from November 4, 2020; however, the issue of entitlement to a TDIU for the period of appeal prior to November 4, 2020, remains on appeal. A TDIU award of benefits may be granted where the schedular rating is less than total, but when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Here, the Veteran’s sole service-connected disability is anxiety disorder, increased herein to 50 percent disabling from January 19, 2017, to November 4, 2020. As such, the Veteran does not meet the requirements for a TDIU prior to November 4, 2020. A TDIU may be granted alternatively on an extra-schedular basis under § 4.16(b) if it is established that the Veteran is indeed unemployable on account of his service-connected disabilities. However, the Board is precluded from granting a TDIU on an extra-schedular basis in the first instance and must refer the matter to the Director of Compensation Service for the initial adjudication. See 38 C.F.R. § 4.16(b); Barringer v. Peake, 22 Vet. App. 242 (2008). If, and only if, the Director of the Compensation Service or designee determines that an extra-schedular TDIU is not warranted does the Board then have jurisdiction to decide the extra-schedular claim on its merits. Here, as noted above, the Veteran contends that he quit working due at least in part to his service-connected anxiety disorder. Thus, the issue of entitlement to a TDIU is being referred to the Director of the Compensation Service for initial adjudication. The matter is REMANDED for the following action: Refer the issue of entitlement to TDIU prior to November 4, 2020, to the Director of Compensation Service for consideration of assignment of an extraschedular rating for TDIU, pursuant to 38 C.F.R. § 4.16(b). Prior to submission of the claim to the Director of Compensation Service, prepare a full statement as to the Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue of entitlement to TDIU prior to November 4, 2020. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Nelson 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.