Citation Nr: 1301286 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 08-23 263 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for bilateral shoulder pain, diagnosed as arthritis of the acromioclavicular (AC) shoulder joints and previously claimed as fibromyalgia, to include as due to an undiagnosed illness and as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for bilateral ankle pain and popping of the ankles, claimed as fibromyalgia, to include as due to an undiagnosed illness and as secondary to service-connected PTSD. 3. Entitlement to service connection for residuals of heat exhaustion. 4. Entitlement to an initial rating in excess of 30 percent for PTSD prior to July 3, 2007. 5. Entitlement to an initial rating in excess of 50 percent for PTSD for the period from July 3, 2007, to September 23, 2008. 6. Entitlement to an initial rating in excess of 70 percent for PTSD for the period from May 1, 2009, to November 22, 2009, and on or after February 1, 2010. 7. Entitlement to an initial rating in excess of 30 percent for migraine headaches prior to September 24, 2008. 8. Entitlement to an initial rating in excess of 50 percent for migraine headaches on or after September 24, 2008. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran served on active duty from October 1981 to October 1984, from June 1985 to June 1991, from August 1999 to August 2002, and from February 2003 to May 2004. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from May 2007 and April 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, and Roanoke, Virginia. In the May 2007 rating decision, the RO granted service connection for PTSD and assigned a 30 percent disability evaluation effective from April 11, 2006. In the April 2008 rating decision, the RO denied service connection for fibromyalgia and heat exposure, but granted service connection for migraine headaches and assigned a 10 percent disability evaluation effective from April 11, 2006. A review of the electronic claims file reveals that it contains evidence pertinent to this appeal that is not associated with the paper claims file, including records of VA treatment as recent as August 2012. During the pendency of the appeal, the Veteran has been granted increased evaluations for his PTSD and migraine headaches. 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 does note that the RO considered the 50 percent evaluation for migraine headaches effective from April 24, 2008, to be a full grant. However, the Board notes that this does not represent the maximum schedular evaluation available for the entire period of the appeal. Therefore, the issue remains on appeal. The Board also notes that the Veteran's appeal had originally included the issues of entitlement to service connection for sexual dysfunction and gastroesophageal reflux disease (GERD) with hiatal hernia; however, during the pendency of the appeal, the RO granted service connection for those disorders in a May 2011 rating decision. Similarly, the appeal had included the issue of entitlement to service connection for fatigue, but the RO indicated in a September 2009 supplemental statement of the case (SSOC) that the disorder would be considered in the disability rating for PTSD. Accordingly, those issues no longer remain in appellate status, and no further consideration is required. Also limiting the potential scope of the claims on appeal insofar as they pertain to service connection for an undiagnosed illness or a chronic unexplained multi-symptom illness (see 38 C.F.R. § 3.317), the Veteran was granted service connection for traumatic arthritis of the wrists (the pain attributable to which was formerly claimed as fibromyalgia, a chronic unexplained multi-symptom illness) and was granted service connection for irritable bowel syndrome (another chronic unexplained multi-symptom illness) in a rating decision dated in May 2011, effective from October 15, 2007. Additionally, the Board notes that the Veteran was granted a total disability evaluation based on individual unemployability due to service connected disabilities (TDIU), in an RO rating decision dated in March 2010, effective from May 1, 2009. The claims file does not reflect that the Veteran has appealed the effective date assigned for a TDIU. The service connection claims on appeal have been recharacterized to reflect new information obtained at March 2011 and August 2012 VA examinations, including X-ray evidence of arthritis in the AC shoulder joints bilaterally, as well as the reasonable expectations of the claimant. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding claimant seeking service connection for disability who has no special medical expertise is not competent to provide diagnosis requiring application of medical expertise to facts such as claimant's description of history and symptoms, and VA should construe claim for service connection based on reasonable expectations of non-expert claimant). The issues of service connection for bilateral ankle pain and popping of the ankles, residuals of heat exhaustion are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. From April 11, 2006, to December 5, 2006, the Veteran's PTSD resulted in occupational and social impairment with reduced reliability, but did not result in occupational and social impairment with deficiencies in most areas. 2. For the period from December 6, 2006, to June 6, 2007, the evidence is at least in equipoise that the Veteran experienced total social and occupational impairment as a consequence of his presenting an imminent threat of harm to himself. 3. For the period from June 7, 2007, forward, aside from those periods for which the Veteran has been hospitalized at VA for PTSD, the Veteran has experienced social and occupational impairment with deficiencies in most areas, including work, family relations and mood. However, he has not experienced total occupational and social impairment. 4. The evidence is at least in equipoise to show that for the full period since April 11, 2006, the Veteran has experienced frequent severe and prostrating headaches. 5. The Veteran has arthritis of the shoulder AC joints bilaterally and has presented credible testimony of the onset of left shoulder symptoms of arthritis in 1999 during active service and right shoulder arthritis in 2004 during active service. The incurrence of wear and tear on the shoulders is consistent with circumstances, places and hardships of the Veteran's duties as a construction equipment repairman in active war zones. CONCLUSIONS OF LAW 1. The criteria for a higher initial disability rating of 50 percent for PTSD, but no more, for the period from April 11, 2006, to December 5, 2006, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a higher initial disability rating of 100 percent, for PTSD, for the period from December 6, 2006, to June 6, 2007, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a higher initial disability rating of 70 percent, but no more, for PTSD, for the period from June 7, 2007, to September 22, 2008, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130, Diagnostic Code 9411 (2012). 4. The criteria for an initial disability rating in excess of 70 percent for PTSD for the periods from May 1, 2009, to November 22, 2009, and from February 1, 2010, forward, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130, Diagnostic Code 9411 (2012). 5. The criteria for an initial disability rating 50 of percent, but no more, for migraine headaches, for the period from April 11, 2006, to September 23, 2008, are met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.124a, Diagnostic Code 8100 (2012). 6. The criteria for an initial disability rating in excess of 50 of percent for residuals of migraine headaches, for the period on or after September 24, 2008, are not met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.124a, Diagnostic Code 8100 (2012). 7. The criteria for service connection for bilateral arthritis of the shoulder AC joints are met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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. 38 C.F.R. § 3.159(b)(1). As the Board grants the Veteran's claim for service connection for bilateral shoulder disability in this decision, further discussion of VA's duty to notify and assist is not required with respect to this claim. An April 2006 VCAA letter explained the evidence necessary to substantiate the claims for service connection for PTSD and for migraine headaches. This letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, the VCAA notice letter from VA was provided prior to initial adjudication of the Veteran's claim and explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The claim for service connection for PTSD was granted in April 2007, and the claim for service connection for migraine headaches was granted in May 2008. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91; see also VAOPGCPREC 8- 2003 (December 22, 2003); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises upon receipt of a notice of disagreement). Thus, VA's duty to notify has been satisfied with respect to the issues of entitlement to a higher initial evaluation for his migraine headaches and PTSD. With regard to the duty to assist, the claims file contains service treatment records, records pertaining to Social Security Administration (SSA) disability benefits, reports of VA post-service treatment, reports of private treatment, and reports of VA examinations. In providing further VA examinations and obtaining the Veteran's SSA disability records, the RO complied with the Board's March 2012 remand instructions in this matter. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (claimant entitled to substantial compliance with remand instructions). In addition, and also in compliance with the Board's March 2012 remand instructions, in letters dated in March 2012 and June 2012, the RO requested that the Veteran provide relevant records pertaining to his disabilities. The June 2012 letter additionally requested that the Veteran complete a VA Form 21-4142, Authorization for Release of Information, for his former railroad employer, so that VA could assist him in obtaining the records. However, the Veteran did not respond to these requests. Such records may have demonstrated the Veteran's level of disability before or at the time his employment at the railroad was apparently involuntarily terminated in approximately March 2007 to June 2007. However, he did not respond to the RO's requests for evidence or for a completed VA Form 21-4142. The duty to assist in the development and the adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996); Zarycki v. Brown, 6 Vet. App. 91, 100 (1993); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran's failure to respond to the March 2012 and June 2012 letters regarding his employment records is a factor in the Board's determination to adjudicate the claims decided below on the merits rather than to seek further relevant medical or employment records. With respect to VA examinations, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As will be discussed in detail below, the extensive SSA records, VA treatment records, and VA examinations regarding the Veteran's service-connected PTSD and migraines are sufficient for application of the rating schedule for rating the Veteran's PTSD and migraine headaches. The records are detailed and extensively reasoned with an accurate view of the Veteran's history and detailed examinations, and they include all necessary findings relevant to the rating criteria. The disability picture is complete so that evidence necessary to adjudicate the claims has been received. Accordingly, the Board finds that the duty to assist in providing VA adequate VA examinations with respect to the claims for higher initial ratings have been satisfied. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal for the claims decided below, and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to those claims. Essentially, all available evidence that could substantiate each claim has been obtained. There is no indication in the claims file that there are additional available relevant records that have not yet been obtained. Service Connection for Bilateral Shoulder Disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prevail on the merits on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances lay, evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established by chronicity and continuity of symptomatology. See 38 C.F.R. § 3.303(b). Continuity of symptomatology may establish service connection if a claimant can demonstrate that (1) a condition was "noted" during service; (2) there is postservice evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet. App. 488, 495-96 (1997)). "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Compensation may be paid to any Persian Gulf War veteran "suffering from a chronic disability resulting from an undiagnosed illness (or combination of undiagnosed illnesses)." 38 U.S.C.A. § 1117. These may include, but are not limited to, muscle pain, joint pain, neurologic signs or symptoms, and symptoms involving the respiratory system. 38 C.F.R. § 3.317(b). Such chronic disability must have manifested either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more no later than December 31, 2016, and must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. Objective indications of a chronic disability include both 'signs', in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) medically unexplained chronic unexplained multi-symptom illnesses that are defined by a cluster of signs or symptoms such as (1) chronic fatigue syndrome (CFS); (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic unexplained multi-symptom illness include, but are not limited to (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; 12) abnormal weight loss. 38 C.F.R. § 3.317(b)(1)-(12) (as effective December 29, 2011) (emphases added). Accordingly, under these regulations service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multi-symptom illness (such as CFS, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. §§ 1117, 1118; 38 C.F.R. § 3.317. Notwithstanding the foregoing presumptive provisions, the Veteran is not precluded from establishing service connection for a disease averred to be related to Gulf War service, as long as there is proof of such direct causation. See generally Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). In each case where a veteran is seeking service-connection for any disability due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence. See 38 U.S.C.A. § 1154(a) (West 2002). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 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 Veteran's DD Form 214 issued in 2004 indicates that his primary military occupational specialty was that of construction equipment repairman, a duty which he performed for four years and five months. His awards and decorations include the Combat Action Ribbon. The award citation indicates that the Veteran came under daily mortar and fire attacks while stationed at Balad Airfield, Iraq, from July 3, 2003, to July 17, 2003. The Veteran's service treatment records contain no specific indication of complaints or a diagnosis of shoulder disability. However, in an April 2004 report of medical assessment, the Veteran complained of pain in his joints that had become worse since his last medical examination and indicated that he had experienced "inflamed nerves in arms not able to drive for 2 weeks x2" since his last physical examination. At a March 2011 VA examination, the Veteran indicated that he began to experience shoulder right shoulder pain in 1991 during a period of active service, and pain in the left shoulder in 2003 or 2004, which was also during a period of active service. He related that his right shoulder pain began after moving barrels while in Iraq, that his left shoulder pain began gradually, and that both continued to bother him. X-rays of the Veterans' shoulders in March 2011 showed mild degenerative changes of the right AC joint and moderate degenerative changes of the left AC joint. The March 2011 VA examiner opined that the Veteran's bilateral AC joint disability was not likely related to service because there was no indication of shoulder complaints or treatment during active service. An August 2012 VA examiner alluded to the possibility that the Veteran's bilateral shoulder arthritis may have been due to an age-related arthritic process that was accelerated by the Veteran's long-term cocaine abuse. The Board finds the opinions of the VA examiners that the Veteran's bilateral shoulder disability to be of significant probative weight. They are based on relevant evidence in the claims file and a fairly accurate history, as well as an examination and X-rays of the Veteran's shoulders. Nevertheless, the probative value of the opinions are diminished somewhat because they tend to discount, without explanation, the history provided by the Veteran of his left shoulder pain beginning during active service in 1999 and his right shoulder pain beginning during active service in 2004. They do not acknowledge the Veteran's documented complaints of joint pains and bilateral arm pain just prior to discharge from service. As the Board evaluates the evidence, competent lay evidence of equal probative weight to the above-described medical evidence is the Veteran's recollection as to when his symptoms of the shoulders began-in 1991 for the left shoulder and 2004 for the right shoulder. The fact that the Veteran's left shoulder AC joint arthritis was shown to be moderately advanced on X-ray in March 2011, while the right shoulder was only mildly advanced on X-ray in March 2011, is consistent with the relative dates of onset as described by the Veteran, with the left shoulder being of earlier onset. This lends credibility to his assertions of date of onset. The Board further notes that wear and tear and strain on the shoulders is consistent with the places, circumstances and hardships of the Veteran's service, including significant periods of service in active war zones as a construction equipment repairman. See 38 U.S.C.A. § 1154(a). As the evidence is in approximate balance, the Board finds the entitlement to service connection for bilateral shoulder disorder, diagnosed as arthritis of the AC joints, is warranted, based on current X-ray results, notations in the service treatment records, and a credible history from the Veteran of onset of the condition during active service. See 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.303(b); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). As the Veteran's bilateral shoulder pain has been found to be attributable to a known diagnosis of arthritis of the shoulder AC joints, consideration for service connection for an undiagnosed illness or chronic unexplained multi-symptom illness is not appropriate for resolution of the claim. See 38 C.F.R. § 3.317. Increased Ratings Claims Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In evaluating the severity of a particular disability it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Claims for higher initial ratings, such as the ones currently on appeal, placed in appellate status by disagreement with the initial rating award and not yet ultimately resolved, are original claims as opposed to a new claim for increase. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 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). Higher Initial Rating--Migraine Headaches The Veteran's migraine headaches are currently rated under 38 C.F.R. § 4.12a, Diagnostic Code 8100. Under Diagnostic Code 8100, migraine headaches are evaluated as follows: a 50 percent rating is assigned with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; a 30 percent rating is assigned with characteristic prostrating attacks occurring on an average once a month over last several months; a 10 percent rating is assigned with characteristic prostrating attacks averaging one in 2 months over last several months; and, a non- compensable rating is assigned with less frequent attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board finds that, affording the benefit of the doubt in favor of the Veteran, for the period from April 11, 2006, to September 23, 2008, the criteria for an increased initial rating, from 30 percent to 50 percent, are met. During initial VA treatment in March 2006, the Veteran presented with complaints including severe chronic headaches. At VA treatment in April 2006, he again indicated that he had problems with severe headaches. He also sought VA treatment in June 2006 for severe headaches and head pain, and he was later seen for migraines in July 2007 with pain rated as 10/10. Certain headache medications were considered, but decided against due to possible adverse effects in combination with his psychiatric medications; thus, medication was limited to ibuprofen. The Veteran described having experienced headaches for the past 2 to 3 years. He described them as frontal and severe, and the Veteran indicated that he usually could not raise his head during the headaches. In August 2007, the Veteran sought VA treatment for migraine headaches with a possible tension component. A CT scan of the Veteran's head was conducted in August 2007 due to concern about his headaches. The diagnoses were essentially normal unenhanced head CT, as well as sinusitis. Records of treatment February 2008 indicate that the Veteran received medications for headaches, and records of treatment in March 2008 described headaches as an active problem. At a March 2009 SSA examination, the Veteran reported having almost daily chronic headaches since 2004. He indicated that they started in the occipital region, and became more generalized in the bifrontal region. It was noted that they were relatively symmetric, and the pain was characterized as a throbbing pain without any nausea, vomiting, photophobia, or phonophobia. He was diagnosed as having migraine headaches. The SSA examiner wrote that these headaches may last as long as four hours and were relieved with lying down and lying in a dark room. The history of brain imaging at VA was also noted. In February 2010 the Veteran was adjudicated as totally disabled by SSA, effective from December 6, 2006, based primarily on his psychiatric disability and headaches, but without consideration of the symptoms of substance abuse. At a March 2011 VA examination, the Veteran described having migraines beginning while he was in Iraq under circumstances related to combat. He stated that they occurred three times per week and lasted a couple of hours each time. He was estimated to have 12 to 16 headaches per month. He also indicated that he had to rest when he experienced a headache. He was currently receiving medication for headaches. Based on the VA treatment and examination records and the history and findings at the March 2009 SSA examination, the Board finds that the evidence is at least in equipoise to show that for the full period from April 11, 2006, to September 23, 2008, the Veteran has experienced migraine headaches manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Accordingly, a 50 percent rating for migraine headaches for the period from April 11, 2006, to September 23, 2008, is warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. A 50 percent rating is currently also in effect from September 24, 2008, to the present. A 50 percent rating is the maximum schedular rating for migraine headaches under Diagnostic Code 8100. Diagnostic Code 8100 is the proper rating code for the reason that it most directly and completely addresses the nature and symptoms of the Veteran's migraine headaches. Accordingly, a rating in excess of 50 percent is not warranted. The Board has also considered whether a referral to the Director, Compensation and Pension, for extraschedular evaluation, in excess of the maximum schedular rating of 50 percent currently assigned for the full rating period on appeal, is warranted for the Veteran's migraine headaches. The governing norm in such exceptional cases is a finding that the case presents such an exceptional or unusual disability picture 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). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the Veteran's symptoms and impairment attributable to service-connected migraine headaches are directly addressed by the rating criteria for a 50 percent rating--very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. These encompass the symptoms and manifestations described for the period from 2004 forward in the treatment records and at the March 2009 SSA consultative examination. Accordingly, referral to the Director, Compensation and Pension, for an extraschedular rating for migraine headaches is not warranted. Thun, 22 Vet. App. at 115. Higher Initial Rating--PTSD When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). When examiners are not able to distinguish the symptoms and/or degree of impairment due to a service-connected versus a nonservice-connected disorder, VA must consider all of the symptoms in the adjudication of the claim. Mittleider v. West, 11 Vet. App. 181 (1998). The Board is to consider the Global Assessment of Functioning (GAF) scores that have been reported in recent years. GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p. 32). GAF scores from 91 to 100 represent superior functioning in a wide range of activities. GAF scores from 81 to 90 represent absent or minimal symptoms. GAF scores from 71 to 80 represent no more than slight impairment of in social, occupational or school functioning. GAF scores of 61 to 70 represent some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or schooling functioning (e.g., occasionally truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e. g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes). Pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, a 10 percent rating for PTSD is assigned where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or where symptoms are controlled by continuous medication. A 30 percent rating for PTSD will be assigned where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss. A 50 percent rating will be 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and 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 worklike setting); and the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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, Diagnostic Code 9411. In April 2006, the Veteran was seen at VA for tiredness and headaches secondary to anxiety. It was noted that he did not have any suicidal ideation, but he was diagnosed by a VA physician as having PTSD. During a September 2006 VA examination, the Veteran was diagnosed as having chronic PTSD. He was noted to have made a suicidal gesture in 1996, but he denied having any other suicidal gestures or attempts, as well as any current homicidal thoughts. There were no signs or symptoms of mania. The Veteran also denied suffering from significant anxiety, panic, obsessions or compulsions. He was noted to avoid talking about traumatic experiences from the Gulf War and to avoid the television on occasion because it brought back upsetting reminders of Iraq. He denied having anhedonia or difficulty recalling important details from his traumatic experiences, as well as having a sense of a foreshortened future. The Veteran did endorse a sense of detachment. He reported that his wife had noted a restricted range of affect, but he acknowledged that this had begun after traumatic incidents of childhood. His wife had also complained that he was not as affectionate since he had returned from the war in Iraq. He reported difficulty sleeping noting he slept about four hours per night. He further described some concentration problems, but denied having hypervigilance. The Veteran also acknowledged feeling angry four days out of the past week, and he reported having one startle response in the past week. He reported having an onset of PTSD symptoms in approximately 2004, and he denied having any periods of remission lasting at least a week. He stated that the symptoms remained about as serious as when he first experienced them. The VA examiner listed the Axis I diagnoses as PTSD and crack cocaine dependence in reported remission, and the Veteran's Global Assessment of Functioning (GAF) score was 65. The examiner opined that the Veteran met the criteria for PTSD and that it was the result of his service in Iraq. The examiner also commented that the PTSD caused only a mild impact upon his level of functioning. He was noted to perform very well at work and to have a positive marriage in general, although his wife complained that he was not as affectionate since his return from Iraq. He was further noted to have a positive relationship with his daughter. He had only one friend, but acknowledged that he had only one friend in high school, so that this was consistent with his behavior prior to entering the military. He was also considered to be competent to manage VA benefits. On December 6, 2006, the Veteran entered a private treatment program for cocaine dependence. The Axis I diagnoses were cocaine dependence, PTSD, and a depressive disorder. The treatment records are not in narrative form and only provide summary findings. The Veteran was noted to be experiencing problems with his primary support group, occupational problems, and problems related to the social environment. He was described as experiencing moderate life stressors. His GAF at admission was evaluated as 41, and his highest GAF over the past year was evaluated as 43. The treatment plan included withdrawal from alcohol or drugs; treatment for insomnia behavior; treatment for depression; and, therapy for his PTSD, among several other "dimensions" of planned treatment. The psychiatric treatment included prescription medications. The treatment ended on March 6, 2007. Subsequent VA treatment records indicate that the Veteran was in "total lockdown" during this treatment. VA treatment records for a subsequent hospitalization from September 2008 to April 2009 indicate by history that the December 6, 2006, period of private substance abuse treatment was precipitated by a suicide attempt in which the Veteran had placed a knife to his wrists and cut himself, but had stopped after he decided he had made a mistake. By history, the level of intent of the incident was high; in the VA staff's assessment, the level of intent of the event was high; and by the VA staff's assessment, the level of lethality of the attempt event was high. (As a result of the December 6, 2006, history of suicide attempt, the Veteran was received into VA treatment in September 2008, during a period of increased depression, as a substantial suicide risk. He has received a 100 percent temporary total rating for the September 2008 to April 2009 period of VA hospitalization. See 38 C.F.R. § 4.29.) During VA treatment in March 2007, the Veteran was diagnosed by a VA licensed clinical social worker as having PTSD with depression. The clinician provided a GAF score of 31. The treatment goal was for the Veteran to remain free of cocaine and alcohol and work on resolving as many PTSD symptoms as possible within the next six months. At VA treatment in June 2007, a VA Internal Medicine physician diagnosed the Veteran as having severe PTSD with concomitant depression. In June 2007, a VA clinical psychologist also diagnosed the Veteran as having Axis I diagnoses of PTSD by history and depression, and an unusual Axis III (physiological) diagnosis of PTSD was rendered, perhaps inadvertently. The clinical psychologist assigned a GAF score of 56. It was noted that the Veteran felt depressed and stressed after losing his job and having his daughter and her baby move in. It was suggested that the Veteran might benefit from PTSD treatment. On a mental health examination, activities of daily living were within normal limits; posture, gait, and motor activity were within normal limits; there were no neurological problems reported; his speech was logical, coherent, and of normal rate, rhythm and volume; his eye contact was fair; he was oriented to person, place and time; sleep was affected by frequent awakening with inability to fall back to sleep, nightmares, and night sweats; appetite was within normal limits; he displayed anergia; he had moderate anxiety and detailed hypervigilance; he presented anger problems in the form of verbal conflicts and frustration with problems with his daughter; his concentration was poor; he had severe short-term memory problems, and moderate long-term memory problems; his thought processes were within normal limits; he experienced social withdrawal; his insight and judgment were intact; his affect was flat; his mood was depressed and agitated; and, he expressed no current suicidal or homicidal ideation or plans. An August 2007 emergency room treatment note documented several complaints of the Veteran, including feeling very tired with no energy and headaches, indicates that on mental status evaluation, the Veteran was alert and oriented times three with good eye to eye contact. The treatment note also indicates that the Veteran denied having any suicidal ideation. At VA mental health treatment in January 2008, the Veteran was noted to be cooperative. He indicated that he had been fired from his job at the railroad and apparently wanted a statement regarding his fitness for duty, but the exact nature of the request was not clear from the clinician. His mood and affect were intense, anxious, and on edge, but his thought processes were linear and goal directed. There was no abnormality of thought content, and he endorsed no suicidal ideation or threats toward others. The Veteran's insight and judgment appeared fair. The treating staff psychiatrist wrote that he politely explained that, as the Veteran was unknown to him, he could not make a statement as to his progress or prior treatment. He offered clinical services to the Veteran, but the Veteran indicated he was not interested. As noted, the Veteran was hospitalized at VA for PTSD from September 2008 to April 2009. His GAF score at admission was 40 and at discharge was 50. He was admitted after experiencing increased depression with emergent non-specific suicidal ideation. He had a history of a suicide attempt in 2006 (more detailed notes of treatment during the hospitalization indicate that this was the precipitating event for his in-patient non-VA private substance abuse treatment beginning December 6, 2006, by cutting his wrists and did not want this to happen again). At the time of discharge, he denied having any suicidal ideation and fully contracted for safety. Other exacerbating factors included daily migraine headaches, active daily PTSD nightmares, and greatly diminished sleep. In a July 2009 rating decision, the Veteran was awarded a temporary total rating of 100 percent for the period from September 24, 2008, to April 30, 2009. The Veteran was again hospitalized for PTSD from November 23, 2009, to January 12, 2010. A temporary total rating has been assigned pursuant to 38 C.F.R. § 4.29 for the period from November 23, 2009, to January 31, 2010. A November 23, 2009, drug screen was positive for barbiturates. His GAF score at admission was estimated at 38, and the discharge GAF score was estimated at 45. At discharge, he denied having any suicidal or homicidal ideations. During a February 2010 VA examination, the Veteran stated that he had suicidal thoughts. He was noted to have been feeling suicidal from October 2009 to November 2009 before the VA hospitalization, but he was found not to have total social and occupational impairment due to PTSD. He was also noted to have significant difficulty with his relationship with his wife and daughter, tending to withdraw. He was found unemployable due to PTSD, as he would inevitably act out in a workplace environment. He was noted to be able to maintain personal hygiene and have no problems with activities of daily living. On memory testing, he could recall three objects immediately, but not after two minutes. A March 2010 record from a suicide prevention case manager indicates that the Veteran was contacted after a phone call was made to the VA suicide hotline. However, he denied having thoughts about suicide or harming others, and he indicated that he felt better after talking to the suicide hotline responder. At a VA examination in February 2011, the Veteran described being depressed every day and almost all day. He acknowledged having passive suicidal ideation without intent or plan. He reported feeling hopeless and stated that he had called the suicide hotline in the past. He described low motivation and fatigue. On examination, the Veteran was clean and appropriately dressed. He was restless and tense, but his speech was unremarkable, and he was cooperative toward the examiner. The Veteran's mood was anxious, but his attention was intact, and he was oriented to person, time, and place. His thought process and content were unremarkable, and he had no delusions. The Veteran's judgment was also sufficient to understand the outcome of his behavior, and his intelligence was average. His insight was sufficient so that he partially understood that he had a problem. He was noted to experience sleep impairment. The Veteran's behavior was appropriate, and he did not have obsessive or ritualistic behavior, panic attacks, or homicidal thoughts. He acknowledged having passive suicidal ideation without intent or plan. In the examiner's opinion, the Veteran did not currently present an imminent danger to himself or others for harm. His impulse control was fair, and it was noted that he did not experience episodes of violence. The examiner found him able to maintain minimum personal hygiene. No impairment of memory was noted on examination interview. With respect to specific symptoms of PTSD, the Veteran was noted to have recurrent, moderately severe to severe intrusive distressing recollections of stressor events, as well as recurrent or distressing dreams of stressor events three times per week. He indicated that he became nervous and jumpy at such cues and stated that his whole day was ruined once he started thinking about the situations. He used medication to try to sleep. The Veteran also indicated that he did not leave his home often and did not go to crowded areas, and he avoided confrontations and crowded areas. He had markedly diminished interest and participation in significant activities, experienced moderate detachment or estrangement from others, had a severely restricted range of affect, and felt paranoid and depressed about his medical problems. The Veteran also had trouble sleeping and was irritable or angry on a daily basis. He had moderate difficulty concentrating, and he experienced exaggerated startle response about twice per week. There were no remissions reported, but there was no evidence to show that he would not be capable of managing his financial affairs. He was noted to have been fired or medically retired from his job at the railroad in 2006. The Axis I diagnoses were PTSD and drug abuse. The February 2011 VA examiner assigned a Global Assessment of Functioning (GAF) score of 50. The examiner commented that the Veteran's symptoms were severe and caused severe impairment in both social and occupational functioning. The examiner further opined that the Veteran's depression was at least as likely as not secondary to his PTSD. The examiner commented that the functional status of the Veteran's psychiatric condition had not changed since the last examination. At a March 2011 VA physical examination, the Veteran was noted to be anxious, as exhibited by him being easily startled, distracted, moving about in his chair, and hypersensitive to any touching of his body. The March 2011 VA physical examiner noted that the examination had to be completed over a two-day period due to extreme emotional distress on the first day. At a VA examination in August 2012 conducted for purposes other than rating his service-connected PTSD, it was noted that the Veteran was married and had a 15 year-old daughter and that he had a good relationship with both of them. He had a normal mental status examination, was acting very appropriately, and was alert and oriented times three. The examiner did note the Veteran's long history of cocaine abuse and noted that a urine toxicity screen on the day of the examination was positive for cocaine. For the rating period from April 11, 2006, to December 5, 2006, the Board finds that a rating of Veteran's PTSD, as most completely evaluated at a thorough and well-reasoned September 2006 VA examination, warrants an increase from 30 percent to 50 percent. The Veteran was found to be doing well at work and to have good family and social relationships. The denied having any recent suicidal gestures or attempts, as well as any current homicidal thoughts, and there were no signs or symptoms of mania. He also denied suffering from significant anxiety, panic, obsessions, or compulsions. However, he was noted to avoid talking about traumatic experiences from the Gulf War and to avoid the television on occasion because it brought back upsetting reminders of Iraq. The Veteran endorsed a sense of detachment, and he reported that his wife had noted a restricted range of affect. His wife had also complained that he was not as affectionate since he had returned from the war in Iraq. The Veteran reported having difficulty sleeping, noting that he slept about four hours per night. He further described some concentration problems, acknowledged feeling angry four days out of the past week, and reported one startle response in the past week. He denied any periods of remission lasting at least a week. Affording the benefit of the doubt in favor of the Veteran, the evidence more nearly occupational and social impairment with reduced reliability and warrants a 50 percent rating. Nevertheless, for this period, the next higher rating of 70 percent is not warranted. For the period prior to December 6, 2006, the preponderance of the evidence shows that the Veteran did not experience occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. His work situation and family relations were described as good. He did not have symptoms such 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 worklike setting); or the inability to establish and maintain effective relationships. Indeed, as noted above, he was found to be doing well at work and to have good family and social relationships As of December 6, 2006, the Veteran's psychiatric treatment reflects a worsened condition, including recurring concerns pertaining to suicidal ideation, as well as other increased symptoms. From this time forward, for the periods for which the Veteran is not in receipt of a temporary total rating of 100 percent, a rating of at least 70 percent is warranted. The medical histories of record indicate that the three-month period of private treatment and rehabilitation beginning December 6, 2006, was necessitated by what is indicated to have been a highly lethal episode of suicidal attempt. Thus, there is evidence that the Veteran required significant treatment because he presented a persistent range of hurting himself. Therefore, the Board finds that a 100 percent rating is warranted for the period from December 6, 2006, to June 6, 2007. As of June 7, 2007, it was affirmatively indicated by a VA clinician that the Veteran was not experiencing current suicidal ideation, so that the preponderance of the evidence shows that the imminent risk of harm to himself had resolved by that time. In this regard, it is also highly probative that the Veteran once again denied suicidal ideation in August 2007 during VA emergency room treatment for multiple complaints. For the additional periods from December 6, 2007, for which a rating of 100 percent is not in effect as a result of VA inpatient psychiatric treatment and hospitalization, a 70 percent rating is warranted, but the next higher rating of 100 percent is not warranted. The evidence consistently shows that the Veteran did not have total occupational and social functioning, as he maintained a functional relationship with his wife and daughter; his thought processes and speech were intact; he had no delusions or hallucinations; his behavior was generally appropriate; he was able to perform his activities of daily living, including maintenance of minimal personal hygiene; he was oriented to time and place; and, he knew the names of the people in his life, his own name, and his former occupation. Thus, for these times, during which the Veteran was not hospitalized and did not present a persistent danger to himself, or for which a temporary total rating is not already in effect, the criteria for a rating of 70 percent, but no higher, are met. See 38 C.F.R. § 4.130 Diagnostic Code 9411. As the preponderance of the evidence is against the claim for a rating for 100 percent for these periods, the benefit of the doubt doctrine is not for application in resolution of this aspect of the Veteran's appeal. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The Board has considered whether a referral to the Director, Compensation and Pension, for extraschedular evaluation, in excess of the assigned schedular ratings of 70 and 100 percent assigned for the rating period on appeal, is warranted for the Veteran's PTSD. The governing norm in such exceptional cases is a finding that the case presents such an exceptional or unusual disability picture 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). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the Veteran's psychiatric symptoms and impairment attributable to his service-connected PTSD, which was most prominently suicidal ideation for the periods for which a 70 percent rating is assigned and presenting a persistent danger to himself for the period for which a schedular 100 percent rating is assigned, are directly contemplated by the rating criteria. The symptoms and levels of impairment considered in assigning the schedular ratings, though very serious and requiring three hospitalizations during the period for consideration, are directly addressed and described in the rating criteria set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, referral to the Director, Compensation and Pension, for an extraschedular rating for PTSD is not warranted. Thun, 22 Vet. App. at 115. ORDER Entitlement to service connection for bilateral arthritis of the shoulder AC joints is granted. Entitlement to a higher initial rating of 50 percent, but not more, for migraine headaches for the period from April 11, 2006, to September 23, 2008, is granted. Entitlement to an initial rating in excess of 50 percent for migraine headaches for the period from September 24, 2008, is denied. Entitlement to a higher initial rating of 50 percent, but no higher, for PTSD, for the period from April 11, 2006, to December 5, 2006, is granted. Entitlement to a higher initial rating of 100 percent for PTSD, for the period from December 6, 2006, to June 6, 2007, is granted. Entitlement to a higher initial rating of 70 percent, but no more, for PTSD, for the period from June 7, 2007 to September 23, 2008, is granted. Entitlement to an initial rating in excess of 70 percent for PTSD for the period from May 1, 2009, to November 22, 2009, and on or after February 1, 2010, is denied. REMAND At a VA examination in August 2012, the examiner prominently noted the Veteran's history of cocaine abuse as a factor for consideration with respect multiple impairments or symptoms for which the Veteran has sought service connection. The Board also notes that an August 2012 urine test conducted for purposes of the VA examination is reported as positive for cocaine metabolite. Such evidence raises the issue of whether the ankle-related or heat-related symptoms or other perceived unexplained multi-symptom physical illness is attributable in whole or in part to his cocaine abuse and whether the Veteran's cocaine use is caused by, a symptom of, or aggravated by his service-connected PTSD and . Therefore, the Board finds that a clarifying medical opinion is necessary in order to better understand the nature and etiology of any current symptomatology. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain a clarifying medical opinion from the VA examiner who conducted the August 2012 VA examination, or, if he is not available, an appropriate clinician, to obtain a clarifying medical opinion as to the questions set forth below. The RO/AMC must send the claims file to the examiner for review, and the clinician must indicate that the claims file was reviewed. The examiner should then respond to the following: (a) Please identify all current diagnoses of a current ankle disorder and state whether the Veteran has fibromyalgia. For each diagnosed disorder identified, is it at least as likely as not that the current disorder is causally or etiologically related to the Veteran's military service or is otherwise related to service? Is it at least as likely as not that the disorder has been caused or aggravated by his service-connected PTSD? If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine whether it is at least as likely as not that such symptoms are due to an undiagnosed illness resulting from service in Southwest Asia during the Gulf War. (b) Does the Veteran have any current residuals of heat exhaustion or exposure and/or any intolerance to heat? If so, is it at least as likely as not such symptomatology is causally or etiologically related to his military service? (c) Is it at least as likely as not that any current ankle and heat problems are caused or chronically worsened by his history of cocaine and alcohol use or his recent or current cocaine use? If so for either disorder, is it at least as likely as not that the Veteran's cocaine abuse or other substance abuse has been caused by, chronically worsened by, or is a symptom of his PTSD with associated depression and fatigue? If further examination of the Veteran is required to provide answers to these questions, the Veteran must be rescheduled for further examinations, tests, or studies, as appropriate. If consultations with other VA clinicians, such as neurology or psychiatric consultations, are deemed necessary to answer these questions, such consultations must be scheduled. In all conclusions, the examiner should identify and explain the medical basis or bases with identification of the relevant evidence of record. The examiner should provide a fully reasoned explanation for his or her opinions, based on his or her clinical experience, medical expertise, and established medical principles. 2. Readjudicate the issues on appeal. If any benefit sought remains denied, provide the Veteran and his representative a Supplemental Statement of the Case and an appropriate period of time for response. Thereafter, subject to current appellate procedure, the case must be returned to the Board for further consideration, if otherwise in order. No action is required of the Veteran until he is otherwise notified by the RO/AMC. By this action, the Board intimates no opinion, legal or factual, as to any ultimate disposition warranted in this case. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These matters must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs