Citation Nr: 1126444 Decision Date: 07/14/11 Archive Date: 07/21/11 DOCKET NO. 07-39 947 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an initial rating for posttraumatic stress disorder greater than 30 percent prior to April 7, 2008. 2. Entitlement to an initial rating for posttraumatic stress disorder greater than 70 percent beginning April 7, 2008. 3. Entitlement to an increased rating for residuals of a shell fragment wound of the right scalp, currently rated 30 percent disabling. 4. Entitlement to an initial rating for a subdural hygroma greater than 10 percent disabling. 5. Entitlement to a separate compensable disability rating for depression and anxiety. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD W. Harryman, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In a May 2011 statement, the Veteran's representative noted that a recent VA examiner indicated that the Veteran would have a difficult time maintaining competitive employment due to his posttraumatic stress disorder (PTSD). Accordingly, the representative explicitly raised the issue of the Veteran's entitlement to a total disability rating based on individual unemployability (TDIU). In addition, the Board observes that consideration of a TDIU is required once a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). When entitlement to TDIU is raised during the adjudicatory process of the underlying disability or during the administrative appeal of the initial rating assigned for that disability, it is part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Moreover, there is no freestanding claim for TDIU. Id. at 451. A TDIU is merely another means of establishing an increased rating. Therefore, the Board will assume jurisdiction of the TDIU issue. FINDINGS OF FACT 1. The competent medical evidence shows that, prior to April 7, 2008, the Veteran's PTSD was manifested primarily by depression and anxiety, occasional nightmares, and sporadic insomnia. 2. The competent medical evidence shows that, beginning April 7, 2008, the Veteran's PTSD was manifested by significant anxiety and depression, as well as constricted, flattened affect, and a paucity of ideas; persistent mannerisms; trouble concentrating; moderate memory impairment; inappropriate behavior; obsessional activities; suicidal ideation; loss of interest in activities; inability to finish tasks, more than slowly; and difficulty following instructions, but without any delusions or hallucinations; grossly inappropriate behavior; danger of hurting himself or others; disorientation; severe memory loss; or inability to perform activities of daily living. 3. The competent medical evidence shows that the residuals of the Veteran's shell fragment wound of the right scalp are manifested by three characteristics of disfigurement and by a painful scar, but without visible or palpable tissue loss or gross distortion or asymmetry. 4. The competent medical evidence shows that the Veteran's subdural hygroma is manifested by headaches and dizziness, but without any neurological manifestations. 5. The competent medical evidence shows that the Veteran's depression and anxiety are part of his service-connected PTSD. 6. The veteran is precluded from obtaining and retaining substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial rating for posttraumatic stress disorder greater than 30 percent prior to April 7, 2008, are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 2. The criteria for an initial rating for posttraumatic stress disorder greater than 70 percent beginning April 7, 2008, are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 3. The criteria for a rating greater than 30 percent for residuals of a shell fragment wound of the right scalp based on disfigurement are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7800 (2010). 4. The criteria for a separate 10 percent rating for residuals of a shell fragment wound of the right scalp based on painful scar are met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2010). 5. The criteria for an initial rating for a subdural hygroma greater than 10 percent disabling are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.124a, 4.130, Diagnostic Codes 8100-9304 (2010). 6. The criteria for a separate compensable disability rating for depression and anxiety are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.14 4.130, Diagnostic Code 9411 (2010). 7. The veteran is individually unemployable by reason of service-connected disabilities. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 3.340, 3.341, 4.1, 4.15, 4.16, 4.19 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to notify and to assist Without deciding whether notice and development requirements have been satisfied concerning a TDIU, the Board is not precluded from adjudicating the issue on appeal herein. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. § 3.102, 3.156(a), 3.159, 3.326 (2010). This is so because the Board is taking action favorable to the Veteran by granting the issue at hand. As such, this decision poses no risk of prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); see also Pelegrini v. Principi, 17 Vet. App. 412 (2004); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). A claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); see also 38 U.S.C.A. § 5103(a). Because the July 2006 rating decision granted the Veteran's claims for service connection for PTSD and a subdural hygroma, such claims are now substantiated. His filing of a notice of disagreement as to the July 2006 rating decision does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2010). Rather, the Veteran's appeal as to the initial rating assignments here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as will be discussed below. The November 2007 statement of the case set forth the relevant diagnostic codes for rating the disabilities at issue and included a description of the rating formulas for all possible schedular ratings under the diagnostic codes. Moreover, the March 2009 supplemental statement of the case provided the Veteran with the recently revised criteria for evaluating residuals of traumatic brain injury (TBI). The Veteran was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above that assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve higher ratings for the service-connected disabilities at issue. The Board also concludes that VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. In addition, the Veteran was afforded appropriate VA examinations in April 2008 and January 2009. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorders since he was last examined. 38 C.F.R. § 3.327(a) (2010). The April 2008 and January 2009 VA examination reports are thorough and supported by VA outpatient treatment records and provided findings pertinent to the rating criteria. The examinations in this case are adequate upon which to base a decision. Therefore, the Board concludes that VA has fulfilled its duty to assist the Veteran in obtaining evidence necessary to substantiate his claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2010). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). The current appeal is based on the assignment of initial disability ratings following the initial award of service connection for PTSD and a subdural hygroma. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Accordingly, evidence contemporaneous with the claim and the rating decision that granted service connection is most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Id. at 126. If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. PTSD PTSD is rated at 30 percent 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, or mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation 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. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where there are, "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. In this case, the RO has already assigned staged ratings for the Veteran's PTSD. A 30 percent rating was initially assigned, effective November 17, 2005. A rating decision in November 2008 increased the rating for PTSD to 70 percent, effective April 7, 2008. Therefore, the Board must consider the appropriate rating for each period, before and after April 7, 2008. VA clinic records show that a psychiatric consult was obtained in March 2005 to evaluate the Veteran's complaint of worsening symptoms of "nerves" including occasional nightmares, sporadic insomnia, intrusive thoughts, and rumination of his Vietnam experiences. He indicated that he enjoyed some recreational activities and visiting friends. He continued to enjoy working on the farm with livestock and tobacco crops. The only abnormal clinical finding noted on mental status examination was a mildly anxious mood. The examiner stated that the Veteran likely had an element of PTSD, but that it did not appear to be disabling at that time. On VA compensation examination in December 2005, the Veteran reported similar symptoms, primarily difficulty falling asleep and staying asleep. Medications had been only partially effective. He stated that his social contacts were mainly with his wife's parents and with his brother, with whom he jointly operated a farm. The Veteran denied any problem with substance abuse. There was no recent suicidal or homicidal ideation. The examiner indicated that the Veteran showed considerable coping capacity, despite ongoing symptoms of PTSD and dysthymic disorder. He had steady employment until the factory where he worked closed, but he continued to actively engage in farming. His problem solving and conceptual ability were slightly impaired, and his concentration seemed reduced. The examiner stated that some of the Veteran's reasoning problems were likely related to situational anxiety. The mental status examination was otherwise normal. The examiner indicated that the Veteran met all the diagnostic criteria for a diagnosis of PTSD, as well as for dysthymic disorder. A GAF score of 61 was assigned, indicating mild to moderate symptoms of PTSD and dysthymic disorder. The Veteran was seen in the VA mental health clinic in February 2007. He had not been receiving any psychiatric treatment and was not on any psychiatric medication. The Veteran stated that the "memories are coming back." He reported having vivid recollections of Vietnam and sleep difficulties, being easily startled by sudden noises, having low energy and trouble concentrating, and he had lost interest in activities. The examiner stated that the Veteran appeared tearful and notably depressed. The Veteran had observed a seasonal pattern to his depression, being worse in the fall and winter months. He admitted to suicidal ideation, but without plan or intent. The Veteran stated that he had "been doing some farming over the past 4 years." On examination, the Veteran's speech was spontaneous, with normal rate, rhythm, and volume. His mood appeared anxious and depressed. His affect was dysphoric. There were no hallucinations, delusions, paranoid thought processes, or thought process disorder. His memory was intact. The examiner stated that the Veteran presented with a severe depressive state, accompanied and complicated by worsening PTSD. The examiner started the Veteran on two medications. In April 2007, the Veteran reported to the same VA examiner that he had been much calmer in disposition and didn't get as excited as he previously did. His sleep was markedly improved. His nightmares were less frequent and less intense, and his energy level was improved. The Veteran's mood was "brighter" and he was beginning to engage in activities that he enjoyed. The examiner indicated that the Veteran still seemed anxious, although he had obtained significant relief of his distressing symptoms. Another VA psychiatric compensation examination was conducted on April 7, 2008. The Veteran reported to that examiner that the medication had helped to reduce his symptoms of chronic anxiety and depression "to some degree." However, he still described himself as feeling anxious and depressed virtually every day, rating those symptoms as 6-7 out of 10 most days. His 26-year old son still lived at home and also worked on the farm. The Veteran described himself as an outgoing person who meets people easily. However, he would rather be alone whenever possible. He liked living in the country, mainly because of the peace, quiet, and solitude that it afforded him. On examination, the Veteran presented with hand wringing and persistent mannerisms, and appeared tense and restless. His speech was slow, and he appeared guarded and apathetic. His affect was constricted, blunted, and flat. The examiner described the Veteran's mood as anxious, depressed, fearful, and dysphoric. He was able to finish cognitive tasks slowly. The Veteran was completely oriented, but he was evasive and displayed a paucity of ideas. The examiner noted that the Veteran expressed suicidal ideation and exhibited obsessions, preoccupation with one or two topics, and ruminations, as well as paranoid ideation. His judgment and insight were intact. There were no hallucinations or delusions. The examiner stated that the Veteran showed some inappropriate behavior in that he would isolate himself whenever he sensed conflict arising with someone. There was no evidence of panic attacks and his impulse control was good. The Veteran's memory was moderately impaired. The examiner indicated that the Veteran's PTSD generally had a moderate to severe effect on his daily activities. The Veteran reported that he worked only half time driving the tractor on his farm, with his son doing the other required labor. The Veteran stated that he could no longer mentally keep up with the tasks of working, sometimes making costly mistakes. The examiner described the Veteran's problems with occupational functioning being related to decreased concentration, difficulty following instructions, increased absenteeism, and memory loss. A GAF score of 50 was assigned. The examiner indicated that the Veteran had been underemployed for the past six years, since losing his previous job. It was noted that the Veteran had no confidence that he would be able to work for someone else. The examiner stated that the Veteran's PTSD symptoms did not produce total occupational and social impairment. However, the examiner commented that it was doubtful that any competitive employer would hire the Veteran because of his numerous functional limitations. Although the Veteran's symptoms of anxiety and depression worsened for a brief period in early 2007, his symptoms showed marked improvement with medication over several weeks. The examiner in February 2007 did note that the Veteran acknowledged suicidal ideation, but without plan or intent; however, in April 2007, suicidal ideation was not mentioned. Moreover, prior to April 7, 2008, there was no evidence of impairment of memory, judgment, or impulse control, or any abstract thinking or other criteria set forth in the Rating Schedule for a rating greater than 30 percent. Therefore, the Board finds that, prior to April 7, 2008, the Veteran's PTSD did not meet the criteria for a rating greater than 30 percent. The GAF score of 61 that was assigned by the December 2005 examiner is indicative of mild impairment, consistent with the Board's finding. Beginning with the April 2008 VA compensation examination, the Veteran displayed significant anxiety and depression, as well as constricted, flattened affect, and a paucity of ideas; persistent mannerisms; trouble concentrating; moderate memory impairment; inappropriate behavior; obsessional activities; and suicidal ideation; he had lost interest in activities; he was able to finish tasks, albeit slowly; and he had difficulty following instructions. However, his speech was spontaneous, but slow; he was completely oriented; there were no hallucinations or delusions; and his judgment and insight remained intact. Those manifestations meet some, but not all of the criteria for a 70 percent rating. Nevertheless, affording the Veteran the benefit of the doubt, a 70 percent rating is warranted, effective April 7, 2008. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4/7 (2010). However, none of the criteria for a 100 percent rating under the Rating Schedule have been described by any examiner. The Board observes that the GAF score of 50 that was assigned by the April 2008 examiner is consistent with a finding of serious, but not total impairment, commensurate with a 70 percent rating. Therefore, because a 70 percent rating is already in effect, beginning April 7, 2008, no higher rating may be assigned. Shell fragment wound of the scalp The criteria for evaluating scars under 38 C.F.R. § 4.118, Diagnostic Codes 7800 through 7805, were revised, effective October 23, 2008. These changes were specifically limited to claims filed on and after October 23, 2008. In this case, the Veteran's claim for an increased rating was received by the RO in November 2005. He did not subsequently request that his disability be reviewed under these clarified criteria. Accordingly, the revised criteria are not applicable in this case and those in effect prior to October 23, 2008, must be applied. Under Diagnostic Code 7800, a 10 percent rating is warranted for disfigurement of the head, face or neck with one characteristic of disfigurement. A 30 percent rating is warranted where there is disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, where there are two or three characteristics of disfigurement. A 50 percent rating is warranted where there is disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, where there are four or five characteristics of disfigurement. See 38 C.F.R. § 4.118, Diagnostic Code 7800 (2010). The eight characteristics of disfigurement are: scar 5 or more inches (13 or more cm.) in length; scar at least one-quarter inch (0.6 cm.) at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). See 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1 (2010). In addition, a 10 percent rating is to be assigned for one or two scars that are unstable or painful. Three or four scars that are unstable or painful warrant a 20 percent rating. A 30 percent rating is assigned for five or more scars that are unstable or painful. See 38 C.F.R. § 4.118, Diagnostic Code 7804 (2010). Other disabling manifestations not considered und Diagnostic Codes 7800-7804 are to be evaluated under an appropriate diagnostic code. See 38 C.F.R. § 4.118, Diagnostic Code 7805 (2010). VA examiners have differed slightly in their descriptions of the Veteran's right-side head scar. A VA compensation examiner in December 2005 indicated that the scar was 0.3 cm by 4 cm and tender to palpation. The scar was not elevated, but it was depressed. There was no ulceration or breakdown. The texture was normal and there was no induration or inflexibility. Further, there was no underlying tissue loss or loss of function. A VA compensation examiner in April 2008 described the Veteran's scar as being 0.5 inch by 4 inches, superior to the right ear. The scar was tender to palpation and adherent to the underlying tissue. There was no loss of function or evidence of ulceration or breakdown, nor was there any underlying tissue loss. However, the scar was noted to be elevated and depressed, and the entire scar was slightly lighter in color than the surrounding skin. The texture of the scar was normal, and there was no induration or inflexibility. Both VA examiners indicated that the scar was not disfiguring. Although the December 2005 examiner described two characteristics of disfigurement, the April 2008 examiner listed three characteristics of disfigurement. Diagnostic Code 7800 provides that when two or three characteristics of disfigurement are shown, a 30 percent rating to be assigned. In this case, the July 2006 rating decision on appeal assigned a 30 percent rating. Therefore, no greater rating may be assigned for the service-connected scar on that basis. However, both of the above VA examiners noted that the scar was tender to palpation. Diagnostic Code 7804 provides that a 10 percent rating is warranted for a scar that is painful. The Board finds that the disfigurement due to the service-connected scar is separate and distinct from the tenderness that has been reported. Therefore, a separate 10 percent rating is warranted for the scar under the provisions of Diagnostic Code 7804. See Esteban v. Brown, 6 Vet. App. 259 (1994) (finding that when a veteran has separate and distinct manifestations from the same injury he should be compensated under different diagnostic codes). In summary, a rating greater than 30 percent for the scar on the right side of the Veteran's head is denied under the provisions of Diagnostic Code 7800. However, a separate 10 percent rating is assigned under the provisions of Diagnostic Code 7804. Subdural hygroma Diagnostic Code 8045 (residuals of brain trauma) (as in effect prior to October 23, 2008) provides that purely neurological disabilities such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., following trauma to the brain, will be rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045-8911). Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under Diagnostic Code 9304. This 10 percent rating will not be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. Effective October 23, 2008, VA amended the Schedule for Rating Disabilities by revising the portion of the Schedule that addresses neurological conditions and convulsive disorders. The effect of this action is to provide detailed and updated criteria for evaluating residuals of traumatic brain injury (TBI). These amendments revised 38 C.F.R. § 4.124a, Diagnostic Code 8045, and were effective October 23, 2008. The amendment applies only to applications for benefits received by VA on or after October 23, 2008, or where the Veteran requests review under the new criteria. See 73 Fed. Reg. 54,693 (September 28, 2008). Here, since the Veteran's service connection claim was received in 2005 and because neither he nor his representative has requested review of the disability under the revised criteria, the amended criteria do not apply. The Veteran claimed service connection for headaches and a brain tumor. An August 2005 rating decision granted service connection for a subdural hygroma and assigned a 10 percent rating under Diagnostic Codes 8100-9304. Diagnostic Code 8100 provides criteria for evaluating migraine headaches. A May 2008 computed tomography (CT) study of the Veteran's head showed findings consistent with a small chronic hygroma or arachnoid cyst lateral to the right temporal lobe, as had been previously noted on CT study in March 2005. The area was unchanged from the March 2005 study and, according to the May 2008 radiologist, was probably of little clinical significance. However, the May 2008 study also showed a possible small remote infarction in the Veteran's brain that was not well documented on the earlier study. No other infarcts or hemorrhages were seen. Both studies were otherwise normal. The records show that the Veteran has undergone several neurological examinations during the course of his appeal, including by VA compensation examiners in December 2005, April 2008, and January 2009. No examiner recorded any abnormal neurological clinical findings. The April 2008 compensation examiner noted that, three days prior to the examination, he awoke with numbness over his left leg and weakness of ankle dorsiflexion. He indicated that the condition had gradually improved, but that he still had some weakness, although sensation was back to normal. But the April 2008 examiner stated that the motor and sensory examinations were completely normal, except for mild decreased sensation to temperature over the right cranial scar, which disability is discussed above. Therefore, a rating based on purely neurological manifestations of the head injury is not warranted. In addition, service connection has also been established for tinnitus, and a separate 10 percent rating is in effect for that disability. The Veteran reported to all three neurological compensation examiners that he had severe pain on the right side of his head every morning, primarily while recumbent. He has described the headaches as like a band around his head and also like an iron bar lying on the side of his head. He has indicated that the pain increases when he opens his mouth. The Veteran has reported that medications help alleviate the pain and dizziness. Neither the Veteran nor the VA examiners have specifically distinguished the Veteran's reported right-sided head pain from his headaches. However, to the extent that he has headaches and dizziness due to the hygroma, Diagnostic Code 9304 precludes a rating greater than 10 percent for purely subjective complaints in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. The May 2008 CT study showed one possible small remote cerebral infarction. But no examiner has diagnosed multiple infarctions, and no examiner has diagnosed dementia due to the brain trauma. Therefore, because a 10 percent rating is currently in effect for the service-connected hygroma, based on the Veteran's headaches, and because a rating greater than 10 percent is specifically precluded by the provisions of Diagnostic Code 9304, an increased rating must be denied. Other considerations Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27. However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2010). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Rating Schedule reasonably describe the Veteran's disability level and symptomatology, then his disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's disability picture regarding his PTSD was not so unusual or exceptional in nature as to render either the assigned 30 percent rating prior to April 7, 2008, or the 70 percent rating beginning April 7, 2008, inadequate. The Veteran's PTSD is evaluated under the General Rating Formula, the criteria of which are found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. 38 C.F.R. § 4.71a, Diagnostic Code 9411. As noted above, the Veteran's PTSD was manifested primarily by anxiety and depression prior to April 7, 2008, but no impairment of memory, judgment, abstract thinking, or impulse control; and by significant anxiety and depression, as well as constricted, flattened affect, and a paucity of ideas; persistent mannerisms; trouble concentrating; moderate memory impairment; inappropriate behavior; obsessional activities; suicidal ideation; loss of interest in activities; ability to finish tasks, although slowly; and difficulty following instructions beginning April 7, 2008. But his speech was spontaneous, although slow; he was completely oriented; there were no hallucinations or delusions; and his judgment and insight remained intact. There was no evidence of persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time and place, or memory loss for names of close relatives, own occupation, or own name. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by a 30 percent disability rating prior to April 7, 2008, and a 70 percent disability rating beginning April 7, 2008, for his PTSD. Ratings in excess thereof are provided for certain manifestations of PTSD but the evidence of record does not demonstrate that such manifestations are present in this case. Accordingly, the criteria for a 30 percent disability rating prior to April 7, 2008, and for a 70 percent disability rating beginning April 7, 2008, more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the assigned schedular evaluations are adequate and no referral is required. The Board finds that the Veteran's disability picture regarding residuals of his right scalp shell fragment wound was not so unusual or exceptional in nature as to render either the assigned 30 percent rating based on disfigurement or the 10 percent rating assigned herein based on tender scar inadequate. The Veteran's right scalp scar is evaluated under the provisions of Diagnostic Codes 7800 and 7804, the criteria of which are found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7804. As noted above, the Veteran's right scalp scar is manifested by three characteristics of disfigurement and a painful scar. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by a 30 percent disability rating based on disfigurement and a 10 percent disability rating based on painful scar. A rating in excess thereof is provided for certain manifestations of a scar of the head or face, but the evidence of record does not demonstrate that such manifestations are present in this case. Accordingly, the criteria for a 30 percent disability rating based on disfigurement and a 10 percent disability rating based on painful scar more than reasonably describes the Veteran's disability level and symptomatology and, therefore, the assigned schedular evaluations are adequate and no referral is required. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms of headaches and dizziness are more than adequately contemplated by a 10 percent disability rating for his subdural hygroma. The Rating Schedule specifically precludes a rating greater than 10 percent for purely subjective complaints, as are shown in this case. Accordingly, no higher rating may be assigned and no referral is required. The Board finds that the Veteran's disability picture regarding residuals of his subdural hygroma is not so unusual or exceptional in nature as to render the assigned 10 percent rating inadequate. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by a 10 percent disability rating. A 10 percent rating is the maximum allowed for purely subjective symptoms. Accordingly, the criteria for a 10 percent disability rating more than reasonably describes the Veteran's disability level and symptomatology and, therefore, the assigned schedular evaluation is adequate and no referral is required. In reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claims for greater ratings at any time during the period pertinent to this appeal, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Hart, 21 Vet. App. 509 (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). Depression and anxiety The December 2005 VA psychiatric compensation examiner noted that the Veteran was depressed and diagnosed dysthymic disorder, as well as PTSD, as discussed above. However, the examiner also indicated that the Veteran's PTSD and his dysthymic disorder were both attributable to combat in Vietnam. The VA compensation examiner in April 2008 also noted that the Veteran was anxious and depressed. However, the examiner indicated that those symptoms, as well as the previously-diagnosed dysthymic disorder, were considered to be part of the Veteran's more global PTSD. VA's regulations specifically preclude evaluation of the same disability under various diagnoses, as this would result in impermissible pyramiding of ratings. See 38 C.F.R. § 4.14 (2010). Therefore, because the Veteran's depression and anxiety are part of his service-connected PTSD and because the ratings assigned for PTSD specifically include consideration of his depression and anxiety, a separate rating for depression and anxiety may not be assigned. TDIU As noted above, the report of the April 2008 VA compensation examination and the May 2011 statement by the Veteran's representative have raised the issue of the Veteran's entitlement to a TDIU. Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: Provided, that if there is only one such disability, this disability shall be ratable as 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. A total rating may also be provided where the evidence demonstrates such an exceptional or unusual disability picture concerning the veteran's service-connected disabilities with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b) (2010). In reaching its determination in this case the Board has followed the analysis of the United States Court of Veterans Appeals (Court) in Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Court held that for a veteran to prevail in a claim for individual unemployability benefits, it is necessary that the record reflect some factor which takes his case outside the norm. 38 C.F.R. §§ 4.1, 4.15. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high schedular rating which is assigned is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether or not the veteran is capable of performing the physical and mental acts required by employment, not whether he/she can find employment. Moreover, there is no statute or regulation which requires VA to conduct a job market or employability survey to determine whether a claimant is unemployable as a result of one or more service-connected disabilities. See Gary v. Brown, 7 Vet. App. 229 (1994); see also Beaty v. Brown, 6 Vet. App. 532, 538 (1994). However, unemployability associated with advancing age or intercurrent disability may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19 (2010). For purposes of entitlement to individual unemployability due solely to service-connected disabilities, marginal employment is not to be considered substantially gainful employment. 38 C.F.R. § 4.17. Factors to be considered, however, will include the veteran's employment history, educational attainment and vocational experience. 38 C.F.R. § 4.16. Service connection is in effect for PTSD, rated 30 percent prior to April 7, 2008, and 70 percent beginning April 7, 2008; residuals of a shell fragment wound of the right scalp manifested by disfigurement, rated 30 percent; residuals of a shell fragment wound of the right scalp manifested by a tender scar, rated 10 percent; residuals of a shell fragment wound of the upper third of the right thigh, rated 10 percent; tinnitus, rated 10 percent; residuals of a subdural hygroma, rated 10 percent; residuals of a shell fragment wound below the right knee, rated noncompensable; and bilateral hearing loss, rated noncompensable; for a combined rating of 60 percent prior to April 7, 2008, and 90 percent beginning April 7, 2008. Thus, the percentage criteria of 38 C.F.R. § 4.16(a) were not met prior to April 7, 2008, but were met beginning April 7, 2008. The record shows that the Veteran has a high school education, although he reportedly took an auto mechanics training course as part of a vocational retraining program several years ago after he lost his job of nearly three decades working at a factory. Subsequently, however, he has worked almost exclusively driving a tractor on his farm. Prior to April 2008, the Veteran operated his farm with his brothers. Although the April 2008 VA compensation examiner stated that the Veteran did not have total occupational and social impairment due to his PTSD, the examiner indicated that the Veteran was then able to work only half time on his farm due to his PTSD symptoms, with his son completing the remainder of the necessary work. The examiner further stated that the Veteran had no confidence that he could handle a job working for someone else. Further, the examiner indicated that the Veteran's prognosis for significant future improvement in his PTSD condition was poor, given his current functional status and his ongoing symptoms. Although the record shows that the Veteran continues to work on a half time basis on his farm, half-time employment is not substantially gainful employment. Moreover, the evidence shows that the Veteran is unable to maintain any other type of work. He has only a high school education, with some vocational training. But his PTSD symptoms would preclude him from that type of work. Therefore, affording the Veteran the benefit of the doubt, the Board finds that he is individually unemployable by reason of service-connected disabilities. 38 U.S.C.A. § 5107(b). ORDER An initial rating for posttraumatic stress disorder greater than 30 percent prior to April 7, 2008, is denied. An initial rating for posttraumatic stress disorder greater than 70 percent beginning April 7, 2008, is denied. An increased rating for residuals of a shell fragment wound of the right scalp based on disfigurement, currently rated 30 percent disabling, is denied. A 10 percent rating for residuals of a shell fragment wound of the right scalp based on painful scar is granted, subject to the law and regulations governing the award of monetary benefits. An initial rating for a subdural hygroma greater than 10 percent disabling is denied. A separate compensable disability rating for depression and anxiety is denied. A total disability rating based on individual unemployability due to service-connected disability is granted, subject to the law and regulations governing the award of monetary benefits. ____________________________________________ L.M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs