Citation Nr: 1312253 Decision Date: 04/12/13 Archive Date: 04/19/13 DOCKET NO. 08-18 872 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent prior to September 5, 2012, and in excess of 40 percent from September 5, 2012, for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips, manifested by undiagnosed illness. 2. Entitlement to an initial rating in excess of 10 percent prior to September 5, 2012, and in excess of 30 percent from September 5, 2012, for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss, and fatigue, manifested by undiagnosed illness. 3. Entitlement to an initial rating in excess of 10 percent for gastrointestinal disorder with complaints of body temperature changes (undiagnosed illness). 4. Entitlement to an initial rating in excess of 10 percent for headaches (undiagnosed illness). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. M. Schaefer, Counsel INTRODUCTION The Veteran had active service from September 1988 to September 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2002 by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire, which granted entitlement to service connection for joint/muscle pain/numbness, right shoulder cervical spine; gastrointestinal disorder; headaches; fatigue; Raynaud's type symptoms (body temperature changes); anxiety disorder, manifested by mood swings, lack of concentration, and memory loss due to undiagnosed illness, with an initial evaluation of 20 percent, effective July 26, 2001. The Veteran appealed the rating decision and in February 2007, the Board remanded the claim for additional development. Following completion of the development requested in the February 2007 remand, in a September 2007 rating decision, the VA Appeals Management Center (AMC) granted separate evaluations of 10 percent for joint and muscle pain involving the right shoulder and cervical spine, 10 percent for gastrointestinal disorder with complaints of body temperature changes (Raynaud's type symptoms), 10 percent for headaches manifested by undiagnosed illness, and 10 percent for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss and fatigue manifested by undiagnosed illness, all effective July 26, 2001. The Board also notes that in the September 2007 rating decision, the AMC assigned the rating of 10 percent for joint and muscle pain involving the right shoulder and cervical spine, manifested by undiagnosed illness under Diagnostic Code 8850-5025, effective July 26, 2001. In a May 2008 rating decision, the RO increased the rating from 10 percent to 20 percent, effective July 26, 2001. Additionally, in a January 2013 rating decision, the AMC increased the rating for the joint and muscle disability to 40 percent, effective September 5, 2012. That rating decision also increased the rating for undifferentiated somatoform disorder from 10 percent, effective July 26, 2001, to 30 percent, effective September 5, 2012. However, as these ratings are still less than the maximum benefit available, the appeal is still pending. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board again remanded the appeal for further development in August 2012, and it now returns to the Board for appellate review. In May 2012, the Veteran testified during a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. FINDINGS OF FACT 1. Prior to April 23, 2007, the Veteran's joint and muscle pain manifested in daily stiffness, and fatigability with flare-ups of slight to moderate pain lasting several hours in the right shoulder and cervical spine as a result of use and activity. 2. From April 23, 2007 forward, the Veteran's joint and muscle pain manifests in pain that was constant or near constant and was refractory to therapy. 3. Prior to August 23, 2007, the Veteran's undifferentiated somatoform disorder was manifested by mild anxiety and minimal memory loss without deficits in speech, thought processes, concentration, insight, or judgment or disturbance of affect; and a Global Assessment of Functioning (GAF) score of 65. 4. From August 23, 2007 forward, the Veteran's undifferentiated somatoform disorder results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks with generally satisfactory functioning due to constricted affect, anxious mood, deficits in attention and concentration leading to impairment of short-term memory, and depression; and GAF scores ranging from 55 to 65. 5. Gastrointestinal disorder with complaints of body temperature changes (undiagnosed illness) is manifested by multiple daily soft or loose stools, frequent abdominal distress and cramping, and bowel disturbance. 6. Headaches are manifested by daily headaches that last up to an hour, which are managed with Ibuprofen and are not prostrating. CONCLUSIONS OF LAW 1. Prior to April 23, 2007, the criteria for an initial rating in excess of 20 percent for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.71a, Diagnostic Codes 8850-5025 (2012). 2. From April 23, 2007 to September 5, 2012, the criteria for an initial rating of 40 percent, but no greater, for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.71a, Diagnostic Codes 8850-5025 (2012). 3. From September 5, 2012 forward, the criteria for a disability rating in excess of 40 percent for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.71a, Diagnostic Codes 8850-5025 (2012). 4. Prior to August 23, 2007, the criteria for an initial rating in excess of 10 percent for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss, and fatigue, manifested by undiagnosed illness have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.130, Diagnostic Code 9423 (2012). 5. From August 23, 2007 to September 5, 2012, the criteria for an initial rating of 30 percent, but no greater, for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss, and fatigue, manifested by undiagnosed illness have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.130, Diagnostic Code 9423 (2012). 6. From September 5, 2012 forward, the criteria for an initial rating in excess of 30 percent for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss, and fatigue, manifested by undiagnosed illness have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.130, Diagnostic Code 9423 (2012). 7. The criteria for an initial rating in excess of 10 percent for gastrointestinal disorder with complaints of body temperature changes (undiagnosed illness) have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.114, Diagnostic Codes 8873-7319 (2012). 8. The criteria for an initial rating in excess of 10 percent for headaches have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.124a, Diagnostic Codes 8881-8100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Stegall Considerations The Board observes that this case was remanded by the Board in February 2007 and August 2012. The United States Court of Appeals for Veterans Claims (Court) has held "that a remand by this Court or the Board confers on the Veteran or other claimant, as a matter of law, a right to compliance with the remand orders." See Stegall v. West, 11 Vet. App. 268, 271 (1998). The purpose of the February 2007 remand was to send the Veteran corrective VCAA notice and to schedule VA examinations. The August 2012 remand was issued to obtain outstanding treatment records and to again schedule VA examinations. A review of the post-remand records shows that the VCAA notice was issued in April 2007 and up-to-date VA treatment records were added to the claims file. The Veteran did not identify any private treatment records he wished VA to obtain. VA examinations were performed in August 2007, May 2008, and September 2012. Therefore, the Board determines that the RO/AMC substantially complied with the Board's orders in the February 2007 and August 2012 remands, and that the Board may now proceed with adjudication of the claims. II. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes certain duties upon VA to notify the claimant of the shared obligations of the claimant and VA in developing his or her claim and to assist the claimant by making reasonable efforts to obtain relevant evidence in support of the claims. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Here, the Veteran is appealing the initial rating assignment as to his service-connected disabilities. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, so any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, thereafter, once a notice of disagreement (NOD) has been filed, for example contesting a downstream issue such as the initial rating assigned for the disability, only the notice requirements for a rating decision and statement of the case (SOC) described in 38 U.S.C. §§ 5104 and 7105 control as to the further communications with the Veteran, including as to what evidence is necessary to establish a more favorable decision with respect to downstream elements of the claim. 38 C.F.R. § 3.159(b)(3) (2012). The RO has provided the Veteran the required SOC discussing the reasons and bases for not assigning a higher initial rating and citing the applicable statutes and regulations. VA has also fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims and providing him with a VA examination. The Veteran's service treatment records, VA medical records, and the reports of October 2001, September 2003, August 2007, May 2008, and September 2012 VA examinations were reviewed by both the AOJ and the Board in connection with adjudication of his claims. The Veteran has not identified any additional, relevant treatment records the Board needs to obtain for an equitable adjudication of the claims. With regard to the VA examinations, the Board notes that once VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, each examiner reviewed the claims file and documented the Veteran's subjective complaints and medical history, and clinically evaluated the Veteran. Thereafter, in the reports they provided information sufficient in detail and relevance to the rating criteria to allow for determination of the appropriate disability ratings. Nothing suggests that any examiner documented findings inconsistent with the medical history outlined in the claims file or not representative of the Veteran's symptomatology; therefore, the Board finds the VA examination reports in this case adequate for rating purposes. Accordingly, the Board concludes that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159 (c)(4). In light of the above, the Board concludes that the medical evidence of record is sufficient to adjudicate the Veteran's claims without further development and additional efforts to assist or notify the Veteran in accordance with VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). Therefore, the Board determines that the Veteran will not be prejudiced by the Board proceeding to the merits of the claims. III. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. As such, the Board has considered all evidence of record in evaluating the Veteran's service-connected disabilities. Also, in Fenderson, the Court discussed the concept of the "staging" of ratings, finding that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, in accordance with Fenderson, the Board has considered the propriety of staged ratings in evaluating the Veteran's service-connected disabilities. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Joint and Muscle Pain The Veteran's joint and muscle pain has been rated as 20 percent disabling prior to September 5, 2012 and as 40 percent disabling thereafter, pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 8850-5025. Diagnostic Code 8850 is used for tracking purposes when rating an undiagnosed illness for a Persian Gulf War Veteran by analogy to one of the musculoskeletal diseases found in VA's Rating Schedule. The Veteran's joint pain has been rated as analogous to fibromyalgia, which is evaluated under Diagnostic Code 5025. That diagnostic code provides that a 20 percent rating is appropriate for symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time. The highest rating of 40 percent is warranted for symptoms that are constant, or nearly so, and are refractory to therapy. 38 C.F.R. § 4.71a, Diagnostic Code 5025 (2012). Widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. 38 C.F.R. § 4.71a, Diagnostic Code 5025. Evidence of record includes multiple VA examinations and treatment records. At the October 2001 VA examination, the Veteran reported pain, weakness, and stiffness in the right shoulder, but no swelling, heat or redness, giving way, or locking. He described daily flare-ups of slight to moderate pain in the shoulder, lasting eight to ten hours and due to lifting and twisting the arm. There was pain in the cervical spine, as well as stiffness and fatigability, but no weakness. Flare-ups were of unknown cause and occurred daily, lasting one to two hours. The Veteran indicated the pain was slight to moderate in the cervical spine. The September 2003 VA examination report documents subjective complaints of painful muscles and joints. The pain could occur anywhere in the body after activity. An August 2007 VA examiner noted that the two main joints that bothered the Veteran were his right shoulder and his neck. The Veteran reported constant, dull pain in both joints that became sharp at times with flare-ups daily. The examiner noted that the Veteran took Ibuprofen or Percocet to relieve pain and that the symptoms had not become refractory to therapy. A May 2008 VA examination report reflects complaints of cervical spine pain constantly without radiation or stiffness. Flare-ups occurred without provocation, though the pain worsened with weather and lifting activities. The Veteran reported slight numbness in his hands. With regard to the right shoulder, he indicated constant pain, weakness, and stiffness, and easy fatigability. Flare-ups lasting from 15 minutes to 24 hours occurred with repetitive movement. The Veteran also endorsed constant pain in the hips, knees, and ankles with stiffness, as well as weakness in the knees. The joints all tired easily. The examiner found that there were no clinically significant findings with regard to any of the joints with the exception of the left ankle, which had suffered a recent fracture. Upper extremity strength was 5/5, and sensation was intact bilaterally. At the September 2012 VA examination, the Veteran had subjective complaints of constant aching throughout his muscles and multiple joints that was aggravated by any sort of movement. The examiner noted that continuous medication was required to control the fibromyalgia symptoms and that the symptoms were refractory to therapy. The symptoms included widespread musculoskeletal pain, with slight generalized stiffness in the morning and fatigue at the end of work days. The examiner indicated that the Veteran's symptoms were constant or nearly constant. Prior to September 5, 2012, the Veteran's joint and muscle pains is assigned a 20 percent rating in contemplation of his daily flare-ups with activity of slight to moderate pain, stiffness, and fatigability lasting several hours in the right shoulder and cervical spine. A 40 percent rating was assigned as of that date as the symptoms had become refractory to therapy and constant or nearly constant. However, the Board finds that the Veteran's symptoms supported a 40 percent rating as of April 23, 2007. Prior to April 23, 2007, the Veteran's symptoms were not noted to be constant or almost constant, flaring for several hours and occurring with use of the joints and activities. The symptoms were also not described as refractory to therapy. However, of record is an April 23, 2007 VA treatment note by the Veteran's primary care physician in which the physician states that the Veteran has pain in multiple joints that may decrease, but never subsides despite taking medication every day. In a June 2007 letter, the physician references that treatment record and specifically states that the pain is constant and refractory to treatment. The Board notes that this statement is contradicted by the August 2007 VA examination report, which identifies constant pain but indicates that the pain is not refractory to therapy. However, the Board determines that this evidence is in equipoise. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert, 1 Vet. App. at 53. The Board has no basis for affording the August 2007 VA examination report greater probative value than the treatment note and statement by the Veteran's treating physician. Accordingly, the Board determines that a 40 percent rating is warranted for the joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips, manifested by undiagnosed illness, effective April 23, 2007. As indicated, a rating in excess of 20 percent is not warranted prior to that date, and there is no rating in excess of 40 percent available pursuant to Diagnostic Code 5025. Therefore, a rating in excess of 40 percent is denied from April 23, 2007 forward. Undifferentiated somatoform disorder The regulations establish a General Rating Formula for rating psychiatric disabilities. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only 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). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The criteria for a 10 percent disability rating are: Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. The criteria for a 30 percent rating are: 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). The criteria for a 50 percent rating are: 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. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent 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 9423. The relevant evidence includes the reports of multiple VA examinations. The Veteran has indicated he has not sought psychiatric treatment. At the October 2001 VA examination, the Veteran reported that his relationships with his wife and children were pretty good. The examiner noted that the Veteran was well-groomed and exhibited normal speech and mild anxiety. Affect was appropriate. There were no indications of depersonalization, derealization, hallucinations, or illusions. Thought processes were goal-directed. Both long- and short-term memory showed minor difficulties. Insight was average, and judgment was good. The GAF score assigned was 65. At a September 2003 VA psychiatric examination, the Veteran exhibited normal speech and appropriate affect. His mood was euthymic. Thought processes were logical and goal-directed. There were no obsessions, delusions, suicidal ideation, or homicidal ideation. The Veteran rated himself at a 6 on scales from 1 to 10 for anxiety and depression, where 10 was relaxed and happy, respectively. He complained of having a spotty memory, but short-term memory testing was within normal limits, as was insight and concentration. The examiner assigned a GAF score of 65 for mild symptoms An August 2007 VA psychiatric examiner noted that the Veteran reported being married for 18 years, indicating that the relationship was "as good as it can be, being married that long" and that his relationship with his five children was decent. He reported having a few friends with whom he socialized. The examiner observed anxious mood and constricted affect. The Veteran indicated that he was depressed about his physical symptoms. Speech was normal and thought process was logical and goal-oriented. The examiner noted mild problems with attention and concentration, resulting in short-term memory issues. Long-term memory was intact. Insight and judgment were within normal limits. The Veteran reported getting six hours of sleep per night, but sleepwalking and waking up at least twice due to chronic pain. The examiner stated that in sum the Veteran's psychiatric symptomatology was of a moderate nature, and he could manage his personal hygiene and daily responsibilities. The GAF score assigned was 55. At the September 2012 mental health examination, the examiner found occupational and social impairment due to mild or transient symptoms with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner stated that the Veteran had diagnoses of undifferentiated somatoform disorder and alcohol dependence and that they accounted for 95 percent and 5 percent of the Veteran's occupational impairment, respectively. The Veteran reported he had been married since 1989 and that the relationship was decent. He also stated that he had a decent relationship with his five children. The examiner noted the Veteran's affect seemed happy and that he was smiling throughout the interview. His thoughts were goal-directed, and he was oriented times 4. Insight and judgment were within normal limits. The Veteran related that he had broken sleep, waking up due to physical discomfort. He denied depression, but endorsed having anxiety most of the time. The examiner noted mild memory loss. A GAF score of 65 was assigned. The Board notes that the Veteran has been assigned GAF scores ranging from 55 to 65. A GAF score of 51-60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF score of 61-70 contemplates some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. While a GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders, the GAF scores assigned in a case are not dispositive of whether overall improvement has been established; rather, they must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). Based on the above evidence, the Board determines that the Veteran's psychiatric symptoms do not more closely approximate a rating in excess of 10 percent prior to August 23, 2007. Before that date, the Veteran exhibited symptoms of mild anxiety and minimal memory loss without deficits in speech, thought processes, concentration, insight, or judgment or disturbance of affect. The Veteran's sleep impairment was caused by his physical pain. These symptoms indicate a mild disability and do not warrant a rating in excess of 10 percent. However, as of August 23, 2007, the Veteran's symptoms more closely approximated a 30 percent rating. The examiner at the August 2007 VA examination indicated that the Veteran's disability was moderate, manifested by constricted affect, anxious mood, deficits in attention and concentration leading to impairment of short-term memory, and depression. Sleep impairment due to pain continued. The Board determines that these symptoms are reflective of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks with generally satisfactory functioning warranting a 30 percent rating. However, the Board finds that the Veteran's symptoms from August 23, 2007 forward do not more closely approximate a rating in excess of 30 percent, including from September 5, 2012 forward. Specifically, the Veteran's psychiatric disability did not manifest in occupational and social impairment with reduced reliability and productivity. While the Veteran had anxious mood and depression and deficits in affect, concentration, and short-term memory, he had no impairment of speech, thought processes, long-term memory, insight, judgment, or abstract thinking. He also did not experience panic attacks. Throughout the appeal period, he maintained at least decent relationships with his spouse and children. In light of these facts, the Board determines that a rating in excess of 30 percent is not warranted for the period from August 23, 2007 onward. Accordingly, a rating in excess of 10 percent for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss, and fatigue, manifested by undiagnosed illness is denied prior to August 23, 2007. From August 23, 2007 to September 5, 2012, a rating of 30 percent, but no greater, is supported by the evidence. A rating in excess of 30 percent is denied from August 23, 2007 forward. Gastrointestinal disorder According to the rating decisions of record, the Veteran's gastrointestinal symptoms have been rated as 10 percent disabling by the RO under the provisions of Diagnostic Code 8873-7304. 38 C.F.R. § 4.114. Diagnostic Code 8873 is used for tracking purposes when rating an undiagnosed illness for a Persian Gulf War Veteran by analogy to one of the gastrointestinal diseases found in VA's Rating Schedule. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Code 7304 evaluates gastric ulcers. However, there is nothing in the medical evidence to suggest that the Veteran has or has ever had an ulcer or symptoms of an ulcer, such as anemia, weight loss, hematemesis, or melena. Moreover, in the January 2013 supplemental statement of the case, the AOJ evaluated the Veteran's gastrointestinal disability in comparison to the criteria for irritable colon syndrome. 38 C.F.R. § 4.114, Diagnostic Code 7319. The Board observes that the September 2012 VA examiner also equated the Veteran's symptoms with those of irritable bowel syndrome. Evaluations for digestive disorders under Diagnostic Codes 7301 to 7329, inclusive 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. See 38 C.F.R. § 4.114 (2012). A single evaluation will be assigned under the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114 (2012). Accordingly, the Board finds that the Veteran's disability is more appropriately rated under Diagnostic Code 7319. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Diagnostic Code 7319 contemplates disability ratings for irritable colon syndrome (spastic colitis, mucous colitis, etc.). A non-compensable rating is assigned for mild irritable colon syndrome with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is assigned for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. At the October 2001 VA examination, the Veteran reported occasional diarrhea and no constipation. There was vague abdominal distress every three to four days lasting a few minutes to an hour. There was no weight loss. In September 2003, the Veteran described soft bowel movements up to three times per day, but no diarrhea. He denied nausea and vomiting, but indicated that he sometimes experienced cramping. In August 2007, the Veteran described constantly feeling bloated and having occasional loose stools. He denied associated vomiting, heartburn, and weight changes. He indicated that he controlled his symptoms by watching what food he eats, and his symptoms have not been refractory to treatment or therapy. With respect to temperature changes, the Veteran described throughout the day having hot flashes or feelings of being cold despite ambient temperatures without any identifiable aggravating or alleviating factors. The July 2010 VA examination report indicates that the Veteran reported soft bowel movements two to three times daily. He denied nocturnal bowel movements and fecal incontinence. The Veteran endorsed feeling nauseous at times, but not constantly; he had no history of vomiting. At the September 2012 VA examination, the examiner noted a diagnosis of irritable bowel syndrome. The Veteran reported having loose bowel movements daily at work in addition to more when at home. He endorsed urgency, but not incontinence. The Veteran described minimal upper abdominal symptoms and heartburn and no constipation, nausea or vomiting, anorexia or weight loss, or watery diarrhea. He reported no current treatment. The examiner described frequent episodes of bowel disturbance with abdominal distress. The examiner stated there was no malnutrition. With regard to changes in temperature, the Veteran reported feeling hot and perspiring or feeling cold out of proportion with the temperature. He indicated that these episodes occur multiple times per day. Based on the above, the Board determines that a rating in excess of 10 percent is not warranted for the Veteran's gastrointestinal disability. The 10 percent assigned contemplates the Veteran's symptoms of multiple daily soft or loose stools, frequent abdominal distress and cramping, and bowel disturbance. A rating in excess of 10 percent is not warranted without diarrhea or alternating diarrhea and constipation and almost constant abdominal distress. The Board observes that the October 2001 VA examination report documented diarrhea, but no constipation. Further, the abdominal distress occurred only every three or four days lasting up to an hour. There were no subsequent reports of diarrhea, and in August 2007, the Veteran reported being able to manage his symptoms with diet. Accordingly, the Board finds that the Veteran does not experience the diarrhea, constipation, and constant abdominal distress necessary to warrant a rating in excess of 10 percent for his gastrointestinal disorder with complaints of body temperature changes. Headaches The Veteran's headaches are currently rated as 10 percent disabling, pursuant to 38 C.F.R. § 4.124a, Diagnostic Codes 8881-8100. He contends that his symptomatology warrants a 50 percent rating throughout the appeal period. Diagnostic Code 8881 is used to indicate neurological disability due to undiagnosed illness. Diagnostic Code 8100 pertains to migraine headaches. Under this provision, a 10 percent rating is warranted for characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent evaluation may be assigned for headaches with characteristic prostrating attacks occurring on an average once a month over the previous several months. A 50 percent evaluation is warranted for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). At the October 2001 VA examination, the Veteran stated that the headaches occurred three times per week, lasting a half hour. They were not prostrating in nature and did not cause vomiting. In September 2003, the Veteran indicated that he got headaches every other day for a half hour. He treated them with Ibuprofen. He denied nausea and vertigo. At the August 2007 VA examination, the Veteran reported a daily dull headache all over his head. He indicated that he took Ibuprofen for his symptoms and that they were not refractory to treatment. In July 2010, the Veteran indicated that he had a headache several times per week that lasted about a half hour to 45 minutes. He related that he might have a more severe headache once per week and that he would stop what he was doing and lie down if that was possible. The Veteran denied fully incapacitating headaches. At the September 2012 VA examination, the Veteran described daily generalized headaches that lasted anywhere from 15 minutes to 45 minutes. He denied prostrating headaches and indicated that he took Ibuprofen as needed, but was not on continuous medication. The Board determines that the above evidence does not support a rating in excess of 10 percent. The 10 percent rating contemplates the Veteran's daily headaches that last up to an hour and which he controls with Ibuprofen. The headaches do not last all day or require the Veteran to rest. A rating in excess of 10 percent is not warranted without a prostrating headache occurring at least once per month. The evidence consistently shows that the headaches are not prostrating. Therefore, the Board determines that a rating in excess of 10 percent for headaches is not supported by the evidence. Extra-schedular ratings and TDIU Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extra-schedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disabilities with the established criteria found in the Rating Schedule for those disabilities. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned ratings inadequate. His joint and muscle pain, undifferentiated somatoform disorder, gastrointestinal disability, and headaches are evaluated under the schedular criteria, which the Board has found to specifically contemplate the level of occupational and social impairment caused by this disability. 38 C.F.R. §§ 4.71a, Diagnostic Codes 8850-5025, 4.130, Diagnostic Code 9423, 4.114, Diagnostic Codes 8873-7319, 4.124a, Diagnostic Codes 8881-8100 (2012). At worst, the Veteran's joint and muscle pains are manifested by constant pain that is refractory to therapy. His undifferentiated somatoform disorder is manifested by occupational and social impairment caused by deficits in affect, mood, short-term memory, concentration, and attention. The gastrointestinal disorder presents in frequent abdominal disturbance with multiple soft or loose bowel movements each day. The Veteran's headaches occur daily lasting up to an hour, managed by pain medication and without causing prostration. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are congruent with the disability picture represented by the disability ratings assigned. Evaluations in excess of that assigned are provided for functional impairment that has not been demonstrated in this case. The criteria for the ratings assigned by the RO and Board reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extra-schedular consideration is not required. See VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Finally, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part and parcel of an increased-rating claim when raised by the record or claimant. The Board has jurisdiction to consider the Veteran's possible entitlement to a TDIU rating in these circumstances when the TDIU issue is raised by assertion, or reasonably indicated by the evidence, and is predicated at least in part on the severity of the service-connected disability in question, regardless of whether the RO has expressly addressed this additional issue. See VAOPGCPREC 6-96 (Aug. 16, 1996). See also Caffrey v. Brown, 6 Vet. App. 377, 382 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993); EF v. Derwinski, 1 Vet. App. 324 (1991). While the evidence indicates that the Veteran's work as a contractor and his income have been affected by his service-connected disabilities, it also establishes that he is still employed despite his disabilities. Therefore, the Board determines that further consideration of TDIU is not warranted. The Board has considered the applicability of the benefit of the doubt doctrine and as discussed applied it in assigning the 40 percent rating for the joint and muscle pains as of April 23, 2007 and the 30 percent rating for undifferentiated somatoform disorder as of August 23, 2007. With regard to the other ratings assigned, as the competent evidence does not support higher ratings for the joint and muscle pains, undifferentiated somatoform disorder, gastrointestinal disorder, and headaches, the preponderance of the evidence is against higher initial ratings for this disability. Therefore, the benefit of the doubt doctrine is not applicable those ratings, and ratings in excess of those assigned must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7. ORDER Prior to April 23, 2007, entitlement to an initial rating in excess of 20 percent for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips is denied. From April 23, 2007 to September 5, 2012, entitlement to an initial rating of 40 percent, but no greater, for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips is granted. From September 5, 2012 forward, entitlement to an initial rating in excess of 40 percent for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips is denied. Prior to August 23, 2007, entitlement to an initial rating in excess of 10 percent for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss, and fatigue, manifested by undiagnosed illness is denied. From August 23, 2007 to September 5, 2012, entitlement to an initial rating of 30 percent, but no greater, for joint and muscle pain involving the right shoulder, cervical spine, knees, ankles, and hips is granted. From September 5, 2012 forward entitlement to an initial rating in excess of 30 percent, for undifferentiated somatoform disorder and anxiety disorder with mood swings, lack of concentration, memory loss, and fatigue, manifested by undiagnosed illness is denied. Entitlement to an initial rating in excess of 10 percent for gastrointestinal disorder with complaints of body temperature changes (undiagnosed illness) is denied. Entitlement to an initial rating in excess of 10 percent for headaches is denied. ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs