Citation Nr: 1237303 Decision Date: 10/31/12 Archive Date: 11/09/12 DOCKET NO. 09-16 702 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada THE ISSUES 1. Entitlement to an initial disability evaluation in excess of 10 percent for the service-connected asthma. 2. Entitlement to an initial disability evaluation in excess of 40 percent for the service-connected interstitial cystitis. 3. Entitlement to an initial compensable disability evaluation for the service-connected migraines prior to July 19, 2012 and to an evaluation in excess of 30 percent beginning on that date. 4. Entitlement to an initial disability evaluation in excess of 30 percent for the service-connected psychiatric disability prior to July 16, 2012 and to an evaluation in excess of 50 percent beginning on that date. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from April 2002 to September 2002 and from January 2005 to May 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an initial November 2008 rating decision of the RO in Roanoke, Virginia. The control of the Veteran's claims file was subsequently transferred to the RO in Reno, Nevada. The Veteran is a participant in the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. In a September 2012 rating decision, the RO found clear and unmistakable error in its November 2008 rating decision with regard to the Veteran's claims for increase involving the service-connected interstitial cystitis, insomnia and asthma. As a result, the initial ratings were increased effective on the date following her separation from service. In the same rating decision, the RO granted service connection for posttraumatic stress disorder (PTSD) and increased the rating for the service-connected migraines. The applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). The Board has rephrased the Veteran's claim for insomnia as a claim for an acquired psychiatric disorder, to include insomnia and PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (stating that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The service-connected asthma is not shown to be manifested by an FEV-1 of 56 to 70 percent predicted or an FEV-1/FVC of 56 to 70 percent or to require daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory. 2. The service-connected interstitial cystitis is not shown to require an appliance to void or the wearing of absorbent materials that must be changed more than four times per day. 3. For the initial period of the appeal, the service-connected migraines is shown to have been manifested by characteristic prostrating attacks averaging one in two months over the previous several months. 4. The service-connected migraines is not shown to have been productive of a disability picture that is manifested by severe economic inadaptability. 5. For the initial period of the appeal, the service-connected psychiatric disability picture is shown to have been productive of occupational and social impairment with reduced reliability and productivity. 6. The service-connected psychiatric disability picture currently is shown to be productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. CONCLUSIONS OF LAW 1. The criteria for the assignment of an initial evaluation in excess of 10 percent for the service-connected asthma have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.96, 4.97 including Diagnostic Code 6602 (2011). 2. The criteria for the assignment of an initial evaluation in excess of 40 percent for the service-connected interstitial cystitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.115a, 4.115b including Diagnostic Code 7512 (2011). 3. Prior to July 19, 2012, the criteria for the assignment of an initial compensable disability evaluation for the service-connected migraines were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a including Diagnostic Code 8100 (2011). 4. Beginning on July 19, 2012 the criteria for the assignment of a evaluation in excess of 30 percent for the service-connected migraines have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a including Diagnostic Code 8100 (2011). 5. Prior to July 16, 2012 the criteria for the assignment of an initial evaluation in excess of 30 percent for the service-connected psychiatric disability were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.20, 4.125, 4.130 including Diagnostic Code 9435 (2011). 6. Beginning on July 16, 2012, the criteria for the assignment of an evaluation in excess of 50 percent for the service-connected psychiatric disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.20, 4.125, 4.130 including Diagnostic Code 9435 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 ("VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice requirements apply to all five elements of a service connection claim: (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 of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). This appeal arises from disagreement with an initial evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated and additional VCAA notice is not required; any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as an effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation of prejudice with regard to the notice in this case, hence further VCAA notice is not required with regard to the initial rating appeal. The Veteran originally received VCAA notice in March 2008. This letter advised the Veteran of what evidence was required to substantiate her initial claims for service connection, and of his and VA's respective duties for obtaining evidence. The letter provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. The duty to assist provisions of VCAA have been met. The claims file contains partial service treatment records (STRs), reports of post-service medical treatment, and reports of the VA examinations in July 2008 and July 2012. The examinations were adequate because they were based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder, and appropriate diagnostic tests. A portion of the Veteran's STRs are apparently not available for review. However, there is no prejudice to the Veteran in the Board's adjudicating her claims without them because they are claims for increased evaluations and the Veteran's symptoms while she was on active duty are not pertinent. The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. She has been given ample opportunity to present evidence and argument in support of her claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2011). Increased Evaluation Claims Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2011). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. If, as here, there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based upon the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). See also AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original rating remains in controversy when less than the maximum available benefit is awarded); Hart v. Mansfield, 21 Vet. App. 505 (2007). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Asthma The service-connected asthma is currently evaluated as 10 percent disabling under Diagnostic Code 6602, bronchial asthma. Under Diagnostic Code 6602, a 10 percent evaluation is warranted when the forced expiratory volume in one second (FEV-1) is 71 to 80 percent predicted, or; the FEV-1/forced vital capacity (FVC) is 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy is required. A 30 percent evaluation is warranted when the FEV-1 is 56 to 70 percent predicted, or; the FEV-1/FVC is 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy is required, or; inhalational anti-inflammatory medication is required. 38 C.F.R. § 4.97. Post-bronchodilator studies are required when pulmonary function tests (PFTs) are used for rating purposes, except when the results of pre-bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator studies should not be performed and explains why. 38 C.F.R. § 4.96. When evaluating a disability based upon PFT results, post-bronchodilator results are used unless they are poorer than the pre-bronchodilator results. In those cases, the pre-bronchodilator results are used. Id. In July 2008, the Veteran underwent a VA examination for her initial claim. She complained of having mild shortness of breath during moderate exertion. She used an inhaler during exacerbations and it eliminated her symptoms. Her PFT results included only pre-bronchodilator responses and no reason was provided as to why post-bronchodilator responses were not recorded. Her FEV-1 was 110 percent predicted. Her FEV-1/FVC was 82 percent. In July 2012, the Veteran underwent a second VA examination in conjunction with her claim for increase. She reported using an albuterol inhaler approximately once per week during exertion. In the previous year she went to the emergency room three times for exacerbations and was treated with a nebulizer. During her most recent episode, she was prescribed a prednisone taper. She reported not using an oral bronchodilator or antibiotics. She did not require oxygen therapy. She did not have any episodes of respiratory failure. The Veteran underwent a PFT in July 2012 and post-bronchodilator responses were recorded. Her FEV-1 was 102 percent predicted. Her FEV-1/FVC was 83 percent. The examiner stated that the FEV-1/FVC was the most accurate representation of the Veteran's disability. The examiner concluded that the asthma did not impact her ability to work. After reviewing the record, the Board finds that service-connected asthma does not meet the criteria required for a 30 percent rating or higher in this case. 38 C.F.R. § 4.7. Although she required nebulizer treatment three times in the year prior to her July 2012 VA examination, her symptoms do not reach the severity needed for a 30 percent evaluation under Diagnostic Code 6602. Her worst PFT results are better than the criteria warranting a 10 percent evaluation, or when the FEV-1 or FEV-1/forced vital capacity (FVC) is 71 to 80 percent of predicted. 38 C.F.R. § 4.97. Further, the evidence does not show that the Veteran requires daily inhalational or oral bronchodilator therapy. Id. The examiner found that she used an albuterol inhaler intermittently. The Veteran reported using it once a week. Lastly, the record does not show that inhalational anti-inflammatory medication is required. Id. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. The service-connected asthma does not met the criteria for a higher rating at any time since the effective date of her award, so the Board may not stage her rating. Fenderson, 12 Vet. App. at 125-26. Interstitial Cystitis The service-connected interstitial cystitis is currently rated as 40 percent disabling under Diagnostic Code 7512, cystitis. 38 C.F.R. § 4.115b. Diagnostic Code 7512 instructs the rater to evaluate it as voiding dysfunction. The criteria for evaluating voiding dysfunction requires that it may be evaluated as urine leakage, frequency or obstructed voiding. 38 C.F.R. § 4.115a. In this case, the Veteran has been found to not have obstructed voiding. Therefore those criteria will not be applied. Under the criteria for urine leakage, a 40 percent evaluation is warranted when there is continual urine leakage, post surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent materials which must be changed two to four times per day. 38 C.F.R. § 4.115a. A 60 percent evaluation is warranted when the urinary dysfunction requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. Id. Under the criteria for urinary frequency, the highest available schedular evaluation is 40 percent, which is warranted when the daytime voiding interval is less than one hour, or awakening to void five or more times per night. Id. In July 2008, the Veteran underwent a VA examination and reported having a daytime voiding interval of every 30 minutes to one hour. Her night time voiding interval was every three hours. She denied having incontinence or problems with her urine stream. In July 2012, at a second VA examination, the Veteran complained of having a constant, full feeling in her bladder. She had urinary leakage that caused her to wear panty liners that she changed twice a day. She did not use an appliance. Her daytime voiding interval was less than one hour, and she awoke five time per night to void. The examiner found that she did not have obstructed voiding, urethral infections, urethral fistula, stricture, neurogenic bladder or a neoplasm. The examiner found that the impact on her ability to work was that her cystitis caused her to need frequent breaks to use the bathroom. In this case, the Veteran's symptoms do not warrant the assignment of a 40 percent evaluation based on urinary frequency, as her daytime voiding interval is less than one hour and she awakens five times per night to void. In addition, the Veteran does not use an appliance. She uses absorbent materials and changes them twice per day. The 60 percent criteria require that the Veteran need to change them more than four times per day. 38 C.F.R. § 4.115a. Therefore, her symptoms do not meet the criteria for an increased evaluation. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. The Veteran's symptoms have not met the criteria for a higher rating at any time since the effective date of her award, so the Board may not stage his rating. Fenderson, 12 Vet. App. at 125-26. Migraines Prior to July 19, 2012 the service-connected migraines were rated at a noncompensable level. Effective on July 19, 2012, the RO increased her rating to 30 percent. The service-connected migraines are evaluated under Diagnostic Code 8100. 38 C.F.R. § 4.124a. A 10 percent evaluation is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent evaluation is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent evaluation is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. A 50 percent evaluation is the maximum available schedular evaluation for headaches. The rating criteria do not define "prostrating." By way of reference, according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." In July 2008, the Veteran underwent a VA examination and complained of severe unilateral headaches that were often accompanied by photophobia. She had them three times a week for several hours. They did responded well to prescription Zomig. The examiner found that the headaches did not cause functional impairment. In July 2012, the Veteran underwent anotherVA examination and was diagnosed with migraine headaches, including migraine variants. She reported taking prescription medication in the past, but not so currently because she did not have health insurance. She took over the counter medications and had headaches three to four times per week. Each week, one headache was incapacitating. She described her headache pain as constant and worse with physical activity. She had pain on both sides of her head, accompanied by nausea and sensitivity to light. Her headaches lasted less than one day. The examiner found that she had characteristic prostrating attacks more frequently than once per month and that her prostrating attacks were very frequent and prolonged. Prior to her July 2012 examination, the Veteran is no shown to have experience characteristic prostrating attacks averaging one in 2 months over the last several months. 38 C.F.R. § 4.124a. She reported having headaches that responded favorably to prescription medication and were not prostrating. After reviewing the record, the Board finds that the overall disability picture for the service-connected headaches prior to July 19, 2012 did not meet the criteria for higher than a 10 percent rating. 38 C.F.R. § 4.7. Therefore, the preponderance of the evidence is against this claim. 38 C.F.R. § 4.3. The RO increased the evaluation for the service-connected migraines to 30 percent effective on the date of her July 19, 2012 VA examination. The examination findings do not include symptoms that meet the criteria for a 50 percent evaluation in accordance with the established rating standards. Although the examiner found that the Veteran's prostrating attacks were very frequent and prolonged, they were not productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The examiner concluded that the Veteran could not concentrate during a severe attack, but did not find that they caused economic inadaptability. After reviewing the record, the service-connected headache disability is not shown to meet the criteria for a 50 percent rating. 38 C.F.R. § 4.7. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. The Veteran's headache manifestations do not met the criteria for a higher rating at any time since the effective date of her award, so the Board may not stage her rating. Fenderson, 12 Vet. App. at 125-26. Acquired Psychiatric Disorder Entitlement to an initial disability evaluation greater than 30 percent for an acquired psychiatric disorder prior to July 16, 2012 and to an evaluation in excess of 50 percent thereafter. Initially, the service-connected psychiatric disability was diagnosed as insomnia and assigned a 30 percent evaluation under Diagnostic Code 9435, for a mood disorder, not otherwise specified. 38 C.F.R. § 4.130. At her July 16, 2012 VA psychiatric disorders examination, the Veteran was diagnosed with PTSD and her disability evaluation was increased to 50 percent. The RO assigned Diagnostic Code 9499-9435. When an unlisted condition is encountered, it may be rated under the Diagnostic Code for a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. When a disability is not specifically listed, the Diagnostic Code will be "built up," meaning that the first two digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be "99." 38 C.F.R. § 4.27. The diagnostic criteria set forth in The American Psychiatric Association: Diagnostic And Statistical Manual Of Mental Disorders, (4th ed. 1994) (DSM- IV) for mental disorders have been adopted by the VA. 38 C.F.R. § 4.125. Psychiatric disabilities other than eating disorders are rated pursuant to the criteria for General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under the General Rating Formula for Mental Disorders, 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is assigned 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 rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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); and inability to establish and maintain effective relationships. Id. Symptoms listed in the General Rating Formula for Mental Disorders 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). It is important to note that a GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). In July 2008, at a VA examination, the Veteran reported having trouble sleeping for the previous two and a half years. She had problems falling asleep on two to four nights per week and problems with staying asleep every night. She had problems "turning [her] mind off." She described her sleep as fitful and denied snoring, nightmares or other parasomnias. The Veteran felt tired during the day due to poor sleep. The Veteran denied having suicidal or homicidal ideation. Her speech, thought processes and behavior were normal. Her memory was good. She did not have obsessions or compulsion. Her insight and judgment were good. She did not have panic attacks. She was diagnosed with primary insomnia caused by medical problems with no discernible etiology. The examiner assigned a GAF score of 60. In December 2008, the Veteran received treatment at VA for anger and insomnia. Her life stressor was her upcoming marriage. She denied having suicidal and homicidal ideation. She was alert and oriented. Her mood and affect were appropriate. Her speech and thought content were normal. She did not have delusions or hallucinations. Her insight and judgment were good. In July 2012 the Veteran underwent a second VA examination and was diagnosed with PTSD and insomnia. She reported not developing friendships or going out in public. She married her spouse in 2009 and had one biological child and two step children. She was a full time home maker. She began attending college full time after separation, but had problems concentrating and paying attention in class. She did not have a history of substance abuse. The Veteran complained of having anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of mood and motivation, difficulty adapting to stressful circumstances, and difficulty establishing and maintaining effective work and social relationships. The examiner concluded that she had no other symptoms attributable to a mental disorder. The examiner found that the Veteran's symptoms caused occupational and social impairment with occasional increase in work efficiency and intermittent periods of inability to perform occupational tasks. A GAF score of 55 was assigned. Prior to her July 2012 VA examination, the evidence of record is sparse with regard to her mental health problems. The evidence does not show disabling finding that would approach or be consistent with occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130. Instead, the Veteran had chronic sleep disturbance with accompanying daytime fatigue. She did not have memory problems, abnormal speech or thoughts, inappropriate behavior, suicidal or homicidal ideation, or impaired judgment. Her GAF score was 60, indicating moderate symptoms. After reviewing the record, the Board finds that the service-connected psychiatric disability picture does not warrant a higher rating prior to July 16, 2012. 38 C.F.R. § 4.7. Therefore, the preponderance of the evidence is against this claim. 38 C.F.R. § 4.3. The only evidence available for the period after July 16, 2012 is the report of her July 2012 VA examination. However, the service-connected psychiatric disability picture does not warrant a rating in excess of percent. Although the Veteran reported having trouble establishing and maintaining effective relationships, she has been married since 2009. The examiner concluded that she had difficulty establishing and maintain relationships, as opposed to being unable to do so. The evidence did not show impairment in judgment, mood, thinking, speech, orientation or impulse control. The evidence did not show that she had poor hygiene or obsessions or compulsions. She reported experiencing anxiety but she did not have near-continuous depression and anxiety. She denied suicidal and homicidal ideation. The record did not show that she had any difficulty functioning appropriately and effectively. Her GAF score was 55, indicating moderate symptoms. After reviewing the record, the Board finds that the overall service-connected psychiatric disability picture does not warrant higher than 50 percent. 38 C.F.R. § 4.7. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. The Veteran's symptoms from a psychiatric disorder have not met the criteria for a higher rating at any time since the effective date of her award, so the Board may not stage her rating further. Fenderson, 12 Vet. App. at 125-26. Extraschedular Evaluations The Board has considered whether referral for an extraschedular rating is appropriate under the provisions of 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As described, the manifestations of the service-connected asthma are contemplated by the schedular criteria set forth in Diagnostic Code 6602, which provides for evaluations based upon her PFT results. The manifestations of her cystitis are accurately described by the rating criteria for voiding dysfunction that account for daytime and night time voiding intervals and use of absorbent materials. The Veteran's headaches are properly contemplated by Diagnostic Code 8100, which provides criteria based upon her frequent prostrating attacks. Her psychiatric disorder symptoms are contemplated by the General Formula for Mental Disorders which provides criteria based upon occupational and social functioning due to symptoms such as chronic sleep disturbance, anxiety, and memory loss. No examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule for any of the Veteran's disabilities. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Total Rating Based Upon Individual Unemployability (TDIU) When entitlement to a total disability rating based on individual unemployability (TDIU) under the provisions of 38 C.F.R. § 4.16 is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A claim for a TDIU rating is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). In this case, the Veteran has not asserted, and the evidence does not show that the Veteran's disabilities have caused unemployability. Because there is no evidence of unemployability, further consideration of entitlement to TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). ORDER An initial evaluation in excess of 10 percent for the service-connected asthma is denied. An initial disability evaluation in excess of 40 percent for the service-connected interstitial cystitis is denied. An initial compensable evaluation for the service-connected migraines prior to July 19, 2012 is denied. An initial evaluation in excess of 30 percent for the service-connected migraines beginning on July 19, 2012 is denied. An initial evaluation in excess of 30 percent for the service-connected psychiatric disability prior to July 16, 2012 is denied. An initial evaluation in excess of 50 percent for the service-connected psychiatric disability beginning on July 16, 2012 is denied. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs