Citation Nr: 1315630 Decision Date: 05/13/13 Archive Date: 05/15/13 DOCKET NO. 09-06 250 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office and Insurance Center in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for benign prostatic hypertrophy (BPH), to include as secondary to exposure to herbicides. 3. Entitlement to service connection for a left eye disability. 4. Entitlement to service connection for a right eye disability, to include as secondary to service-connected disabilities. 5. Entitlement to an initial compensable rating for migraine headaches. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Dr. H.C. ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from September 1965 to September 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2008 and November 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In March 2013, the Veteran testified via video conference before the undersigned. A transcript of the hearing is associated with the claims file. At the hearing, the Veteran submitted additional evidence in the form of a November 2012 private medical report. He waived initial RO consideration of the newly submitted evidence. See 38 C.F.R. § 20.1304 (2012). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that certain documents, including the March 2013 video conference hearing transcript, are potentially relevant to the issues on appeal. Thus, the Board has considered these electronic records in its adjudication of the Veteran's case. Any future consideration of this appellant's case should also take into consideration the existence of this electronic record. The issues of service connection for BPH, right eye disability, and left eye disability 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. The evidence is in equipoise that the Veteran has a diagnosis of PTSD in conformance with the standards of DSM-IV; there is credible supporting evidence that a claimed in-service stressor occurred; and the positive medical evidence of record links the diagnosis of PTSD to the in-service stressor. 2. The Veteran's migraine headaches are non-prostrating. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for PTSD have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The criteria for an initial compensable rating for migraine headaches have not been met. 38 U.S.C.A. §§ 1155, 5107, (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.7, 4.120, 4.124a, 4.129, 4.130, Diagnostic Code 8100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Given the Board's favorable disposition to grant the claim for service connection for PTSD, the Board finds that no discussion of VCAA compliance is necessary at this time for this issue. Regarding the claim for increased rating, the notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In a January 2008 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate the underlying claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The January 2008 letter also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. Moreover, the appeal arises from the initial award of service connection. In Dingess, the Court held that in cases in which 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. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i) (2012). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, service personnel records, deck logs for the U.S.S. Southerland, Internet medical treatises, VA and private medical records, VA examination reports, and hearing testimony. The Board finds that the VA examinations conducted in connection with the rating claim are adequate because the examiner (who conducted all three exams) was informed of the relevant facts regarding the Veteran's medical history and addressed the relevant rating criteria. The Veteran has been afforded a Board hearing in which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c) (2) (2012) requires that the "hearing officer" who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the hearing the undersigned enumerated the issue on appeal. Also, the undersigned noted the bases of the prior determinations or the elements that were lacking to substantiate the Veteran's increased rating claim and the evidence necessary to substantiate the claim. Thus, the obligations under 38 C.F.R. 3.103(c)(2) are met. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument, including at a video conference hearing. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). PTSD Establishing service connection for PTSD generally requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2012); see also Cohen v. Brown, 10 Vet. App. 128 (1997). If the veteran did not serve in combat, or if the claimed stressor is not related to combat, there must be independent evidence to corroborate a veteran's statement as to the occurrence of the claimed stressor. See Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). Generally, the Veteran's testimony alone cannot establish the occurrence of a non-combat stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Furthermore, an opinion by a medical health professional based on post-service examination of the Veteran cannot be used to establish the occurrence of a stressor. See Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). However, effective July 13, 2010, if a stressor claimed by a veteran is related to that veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that a veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of that veteran's service, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. "[F]ear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 75 Fed. Reg. 39,843 (Jul. 13, 2010) (codified at 38 C.F.R. § 3.304(f)(3)). For reasons detailed below, the Board finds that service connection may be established for PTSD under the old regulation. In this case, the Veteran asserts that he has PTSD due to several stressors including as a result of being subject to small arms fire and sniper fire from the shoreline and his unit firing its guns while stationed in the official inland waters of Vietnam. Information obtained from the National Personnel Records Center (NPRC), deck logs, and service personnel records show that the Veteran served aboard the U.S.S. Southerland in the official inland waters of Vietnam from July 9, 1966 to July 30, 1966. The deck logs show that the U.S.S. Southerland was assigned to Naval gunfire support duties in the Vietnamese II Corp area. The deck logs verified the U.S.S. Southerland fired upon targets in Vietnam and the ship hammered Viet Cong emplacements. The deck logs did not show that the U.S.S. Southerland was fired upon or hit by sniper fire. In conceding the Veteran was in the general proximity of the attacks, the RO referenced the principles set forth in Pentecost v. Principi, 16 Vet. App. 124, 128-29 (2002); Suozzi v. Brown, 10 Vet. App. 307 (1997). The Board agrees. Once the claimed stressor has been verified, the veteran's personal exposure to the event may be implied by the evidence of record. A veteran need not substantiate his actual presence during the stressor event; the fact that the Veteran was assigned to and stationed with a unit that was present while such an event occurred strongly suggests that he was, in fact, exposed to the stressor event. Id. Here, in addition to being fired upon, the Veteran also claims that the exposure to his unit firing its guns (and hitting a fisherman who was killed) was also stressful. The deck logs verify that the U.S.S. Southerland fired upon targets in Vietnam; the Veteran's personal exposure to the event is implied. Accordingly, there is credible supporting evidence that a claimed in-service stressor occurred. In regard to evidence of a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a), and a link between the diagnosis of PTSD and an in-service stressor, the evidence shows that there are conflicting medical opinions of record with regard to the matter of whether the Veteran has PTSD due to service. The Board must therefore weigh the credibility and probative value of these opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Service treatment records are negative for any complaints or treatment for PTSD. On separation examination in September 1967, the Veteran reported no psychiatric complaints, and he was found to have no psychiatric abnormalities. In October 2007 and April 2011 psychological reports from Dr. H.C., the Veteran was diagnosed with chronic, moderate PTSD with depressive features. The Veteran complained that upon returning to civilian life after discharge from service, he was angry and irritable. He reported having sleep problems accompanied by bad dreams. He also stated that he had experienced frequent, severe panic attacks after his return from Vietnam, although he reported that these attacks had diminished over time. The Veteran had been prescribed Valium for these anxiety attacks after his return to civilian life. He maintained that he suffered from intrusive thoughts of the people that he served with in Vietnam, which brought on feelings of sadness and guilt for having returned from the war safely. He indicated that he was obsessed with watching Vietnam war movies and documentaries, but had little understanding of his behavior. Dr. H.C. noted that the Veteran's wife had refused to come to the treatment session because she "did not want to open a can of worms." He reported that the Veteran's affect was flat with moderate buoyancy, and his mood was sad and sullen. He appeared to be depressed. The Veteran was also noted to be tense, edgy, and subject to episodes of high anxiety. He was worried that he would exaggerate his Vietnam experiences and stated several times that other people's contributions had been greater than his own. Dr. H.C. found that in doing so, the Veteran minimized his own experience, especially the affect related to his depression and the loss of lives at a young age. The Veteran had poor sleep with frequent awakenings. Although his dreams had diminished over time, he still had occasional dreams. His insight into his problems was poor. Dr. H.C. found that the Veteran's tendency was to deny psychological problems and that in essence, he presented a picture that minimized his condition. The Veteran's primary defenses were avoidance-oriented, and he worked to defend against anything negative. He was found to present symptoms of reexperiencing, hyperarousal, and avoidance with psychic numbing. On VA examinations in January 2010 and September 2011, the VA examiners did not find that the Veteran met the DSM-IV criteria for PTSD. Indeed, the Veteran received no Axis I diagnosis from either VA examiner. The January 2010 VA examiner explained that the Veteran was not persistently reexperiencing his trauma, avoiding stimuli, or having persistent increased arousal. She noted that his mood was generally good and that he denied excessive anxiety or worry. Specifically, the examiner noted that traumatic events were occasionally reexperienced and triggered by war movies, but the Veteran did not report high distress when remembering his Vietnam experiences. He only had one or two nightmares a year about his war experiences. As far as avoidance, the Veteran indicated that he would not discuss his Vietnam experiences for about 15 years after he returned from Vietnam, but he had been talking about his experiences more freely in the last 20 years. He maintained that he had stopped talking about Vietnam because he had felt ashamed for being there, but he had not repressed it because of distress over the experiences and traumas in Vietnam. The Veteran also denied feeling diminished interest in activities. He reported that he had experienced outbursts of anger and irritability when he first returned from service, but he stated that he had not had that problem for the last 20 years. The Veteran also endorsed some symptoms of exaggerated startle response, hypervigilance, and occasional trouble with falling asleep. The September 2011 VA examiner reported that although the Veteran had some current intrusive thoughts of his Vietnam experiences, he was not reporting significant distress associated with these thoughts. She indicated that the Veteran's report of reexperiencing symptoms appeared to be historical in that he experienced some of these symptoms in the past after he returned from Vietnam. She also noted that the Veteran denied persistent avoidance of stimuli and numbing of general responsiveness. In particular, the Veteran indicated that he discussed his Vietnam experiences with his wife, but she did not like for him to talk about them because it was "opening up a can of worms." The Veteran stated that he instead would discuss his experiences with certain representatives at veterans service organizations because it seemed to help him. He also denied avoiding war movies and maintained that he did not have diminished interest in formerly enjoyable activities. He reported that he enjoyed wood working, working on his car, and going to stores with his wife. He also denied a restricted range of affect, a sense of a foreshortened future, or having feelings of detachment or estrangement from his family. The examiner found that the Veteran did have some symptoms of increased arousal in the form of chronic sleep disturbance, some hypervigilance, and some startle response for loud noises, but stated that it did not appear to affect his functioning. The September 2011 VA examiner concluded that the Veteran did not have a PTSD diagnosis because he was not persistently reexperiencing intrusive distressing recollections of his trauma or avoiding stimuli, and because he reported good functioning in terms of his social and employment history. The VA examiner noted that the Veteran had provided information that was consistent with what he reported at his January 2010 VA examination. She found that while the Veteran did have some PTSD symptoms and likely would have met the criteria for PTSD immediately following his Vietnam service or even within the first 10 years of his return, he did not currently meet the criteria for a PTSD diagnosis. She explained that what may account for the distinctive discrepancy between Dr. Cohen's findings and the January 2010 VA examiner's findings was the fact that Dr. Cohen had appeared to focus on the historical experience of the Veteran's symptoms while the January 2010 examiner had focused on the Veteran's current functioning. In a July 2010 VA behavioral health laboratory consultation, based on the answers that the Veteran provided in a telephone interview, he was diagnosed with depressive disorder. The VA psychologist indicated that the Veteran reported trauma but did not meet the criteria for PTSD. Specifically, the Veteran had maintained that he was not bothered at all by avoiding thoughts, avoiding activities, trouble with recall, loss of interest, feeling distant, feeling numb, feeling life is shortened, irritability, difficulty concentrating, feeling nervous, and being easily startled. During the March 2013 video conference hearing before the Board, Dr. H.C. testified in support of the Veteran's claim. Testimony revealed, in pertinent part, that Dr. H.C. had a Ph.D. in clinical psychology with an American Psychological Association-approved post-doctorate in clinical psychology and consistently worked with veterans and "provide(d) treatment and evaluations and work[ed] in concert with the VA in terms of concerns over compensation and pension issues." Dr. H.C. testified that the Veteran's wife did not want the Veteran to testify at a hearing because she had an issue with how people with mental problems were being labeled. She also did not want the Veteran to take any medication for his disability and had refused to attend the October 2007 treatment session with Dr. H.C. because she wanted the Veteran to just forget Vietnam and push away any negative memories. Dr. H.C. reported that the Veteran did have upsetting thoughts of his Vietnam experiences when he watched news footage of the current conflicts in Iraq or Afghanistan, and that he experienced sadness and sometimes cried when he saw the news on the television or in newspapers. He also had some physiological reactivity to loud noises. Regarding the criterion for avoidance, Dr. H.C. clarified that although the Veteran's wife may have discussed the historical aspects of the Vietnam War or of the ship that the Veteran served on, her tendency was to pull back from any discussion of the Veteran's personal feelings regarding his Vietnam experiences. The Veteran tended to avoid talking about his personal experiences of Vietnam. He was always on the positive side of any conversation about Vietnam and constantly qualified his statements and minimized his expression to prevent overexaggeration of his experiences. Although the Veteran went food shopping with his wife and claimed to have loving feelings, Dr. H.C. found that he actually had restricted affect and would avoid crowds. The Veteran also refused to eat rice because it was a reminder of his Vietnam experiences. Dr. H.C. explained that the Veteran was a repressor and did not share information or deep personal thoughts with anyone because he was afraid to deal with the past and create family strife by upsetting his wife. He indicated that avoidance was a psychological defense mechanism that protected an individual from anxiety and the awareness of internal and external threats. He stated that the Veteran used the avoidance defenses of denial, a refusal to acknowledge painful aspects of his trauma in order to deal with stress, and attributing his own unacceptable feelings and impulses to another person. He maintained that the Veteran's wife enabled his avoidance because she equated positive mental health with thinking about something else and forgetting your past experiences. With respect to increased arousal, Dr. H.C. testified that the Veteran suffered from hypervigilance, exaggerated startle, and difficulty falling or staying asleep. The Veteran had exaggerated startle and response to noises such as the backfire of cars, firecrackers, or helicopters. Dr. H.C. also reported that prior to his job at Cummings where he had worked for 15 years, the Veteran had had 30 different jobs. An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993); Gabrielson v. Brown, 7 Vet. App. 36 (1994). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). The Board finds that the October 2007, April 2011, and March 2013 opinions from Dr. H.C. show that the Veteran suffers from chronic PTSD related to his in-service stressors in Vietnam while the findings of the January 2010, July 2010, and September 2011 VA examiners indicate that the Veteran does not meet the diagnostic criteria for PTSD. The October 2007, April 2011, and March 2013 opinions were based on a detailed examination of the Veteran, which reflected a knowledge of his in-service stressors and post-service mental health history. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). Dr. H.C. also provided a rationale for why the Veteran met the PTSD criteria for avoidance stimuli. Sklar v. Brown, 5 Vet. App. 140 (1993). Specifically, Dr. H.C. indicated that although the VA examiners had found that the Veteran did not have avoidance stimuli, this was because the Veteran used avoidance as a defense mechanism. He always stayed on the positive side of any conversation about Vietnam and constantly qualified his statements and minimized his expression to prevent overexaggeration of his experiences. Dr. H.C. explained that in order to protect himself from anxiety and the awareness of internal and external threats, the Veteran constantly resorted to denial, a refusal to acknowledge painful aspects of his trauma in order to deal with stress, and attribution of his own unacceptable feelings and impulses to another person. Dr. H.C. also reported that the Veteran's wife enabled him to use avoidance as a defense mechanism because she equated positive mental health with just forgetting about past experiences. Dr. H.C.'s reports also show that the claimed stressors, including the Veteran's unit firing its guns and killing a fisherman are the basis for the PTSD diagnosis. The January 2010, July 2010, and September 2011 VA opinions were also based on a detailed examination of the Veteran reflecting a knowledge of his in-service stressors and post-service mental health history, and supported by rationale. Prejean v. West, 13 Vet. App. 444; Sklar v. Brown, 5 Vet. App. 140. The September 2011 VA examiner acknowledged that it was likely that the Veteran would have met the criteria for PTSD immediately following his Vietnam service or even within the first 10 years of his return, but found that he currently did not meet the full criteria for PTSD. The examiners determined that although the Veteran had some recollections of his trauma, he did not persistently reexperience it, nor were his recollections distressing. As the Veteran denied any avoidance stimuli, diminished interest in activities, a restricted range of affect, a sense of a foreshortened future, or having feelings of detachment or estrangement from his family, the examiners also determined that the Veteran did not make an effort to avoid stimuli. They also noted that he reported good functioning in terms of his social and employment history. In sum, the Board finds that there is credible supporting evidence that a claimed in-service stressor occurred. The issue of whether there is a diagnosis of PTSD in conformance with DSM-IV is balanced by positive and negative evidence. Therefore, the Board concludes that the balance of positive and negative evidence is at the very least in relative equipoise. Where the evidence supports the claim or is in relative equipoise, the appellant prevails. Reasonable doubt is resolved in favor of the Veteran, and the Board finds that the Veteran has a current diagnosis of PTSD. 38 U.S.C.A. 5107 (b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The positive medical evidence of record links the diagnosis of PTSD to the corroborated in-service stressor. Accordingly, service connection for PTSD is warranted. Also, the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran's specific contention is that he suffers chronic mental disability from in-service stressful events. The chronic mental disability resulting from the in-service stressful event has been clinically identified as PTSD. As the Board finds that service connection is warranted for PTSD, a full grant of the benefit sought on appeal has been awarded. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Service connection for migraine headaches was granted by the May 2008 rating decision, with a noncompensable rating assigned, effective November 23, 2007. The Veteran's disability is rated under Diagnostic Code 8100, which contemplates migraines. Under Diagnostic Code 8100, a noncompensable evaluation is warranted for less frequent attacks. A 10 percent rating is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). On VA examination in April 2008, the Veteran reported having suffered headaches since discharge from service. He stated that he had not seen a health care professional for these headaches and that he treated them himself with Tylenol. He indicated that the headaches were in the left frontal area and that they were not associated with nausea or vomiting. He maintained that the headaches were non-prostrating and that he was able to work through them. He denied missing any work due to his headaches. Examination revealed full and disconjugant extraocular muscles and a strabismus of the left eye. Pupils were equal and reactive to light, gait was stable, and deep tendon reflexes were 2+ and symmetrical. Finger-to-nose testing was normal. The Veteran was diagnosed with non-prostrating headaches. The examiner noted that the Veteran was able to function with the headaches. At a February 2010 VA examination, the Veteran reported that he experienced approximately one headache every 1 to 2 months that lasted 3 to 4 hours in duration. He indicated that these headaches were non-prostrating and that he was able to function during the course of these headaches. Examination revealed full and conjugate extraocular muscles and an esotropia of the left eye. Right disk margin was sharp. Deep tendon reflexes were 2+ and symmetrical, and gait was stable. The Veteran was again diagnosed with non-prostrating migraine headaches. On VA examination in April 2012, the examiner noted that the Veteran had a history of headaches for which he was not actively seeking medical care. The Veteran reported having 2 headaches a month that lasted about 2 days in duration. His headaches were bitemporal, had a throbbing quality to them, and were not associated with other symptomatology. The Veteran took Excedrin to treat his headaches. His activities of daily living were independent during the headaches. Neurological examination was normal. The examiner diagnosed the Veteran with non-prostrating migraine headaches. The Veteran testified before the Board at a March 2013 video conference hearing. Testimony revealed, in pertinent part, that the Veteran did not take Excedrin for his headaches due to his heart issues, but that he took extra-strength Tylenol to treat his headaches. The Veteran testified that he experienced really bad migraine headaches about 2 or 3 times a month. He reported that the headaches caused bad pains on the side and back of his head and prevented him from going outside if it was sunny. He stated that when he had his headaches, he would be sensitive to loud noises and bright light. He indicated that during a migraine episode, he would wear really dark sunglasses if he had to go outside. He maintained that during his migraines, he also felt nausea to the point where he almost wanted to throw up. He reported that his headaches would last anywhere from 2 to 3 hours to 2 to 3 days. He stated that he would just take Tylenol for his headaches and wait for them to pass. He indicated that he avoided seeking formal medical treatment for his headaches because he disliked taking a lot of medication due to the possibility of getting too many side effects. The Board finds that the evidence does not support an initial compensable rating for the Veteran's migraine headaches. The Veteran has recently reported experiencing migraine headache episodes about 2 to 3 times a month that lasted from 2 to 3 hours to 2 to 3 days. However, the medical evidence does not show that these headaches are prostrating. Indeed, the April 2008, February 2010, and April 2012 VA examiners all found that the Veteran's headaches were non-prostrating and that he was able to function during the headaches. The Board is cognizant of the Veteran and his representative's contention that the 2012 VA examination report contained "factually inaccurate information." Specifically, the Veteran contends that he reported he treated his headaches with Tylenol rather than Excedrin and that he experienced photophobia, nausea, and phonophobia during his headaches. The Board does not find any error in the VA examiner reporting Excedrin rather than Tylenol significant as both are over the counter drugs. Also, the Board cannot find the Veteran's assertion that his headaches are accompanied by photophobia, nausea, and phonophobia credible because when given the opportunity to report on these symptoms to the 2012 VA examiner he did not do so. The Board is also not persuaded that the Veteran reported on these symptoms but the 2012 VA examiner neglected to record the symptoms because in prior VA examinations in 2008 and 2010, the Veteran did not complain of these symptoms. Based on the Veteran's reports and the physical examination, the VA examiners did not find that the Veteran suffered from prostrating attacks. Thus, the lay evidence is outweighed by competent and credible medical evidence that evaluates the true extent of the headache impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluation assigned and do not more nearly approximate the criteria for a higher evaluation at any time during all relevant periods on appeal. See 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012); see also Fenderson, supra. The Board has also considered whether the Veteran's migraine headaches present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. There was no credible evidence that the Veteran's headaches were prostrating. The Veteran has not described any unusual or exceptional factor associated with his headache disability. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. The Board recognizes that the Court of Appeals for Veterans Claims has clarified that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities exists as part of a claim for an increase (whether in an original claim or as part of a claim for increased rating). Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). The record reflects that the Veteran filed a claim for TDIU in October 2011 in which he claimed he was unemployable but due to several disabilities (ischemic heart disease, PTSD, and migraine headaches). The Board notes that the RO denied entitlement to TDIU in a May 2012 rating action. In Locklear v. Shinseki, the Court distinguished the instant case from Rice and recognized that VA's Secretary specifically separated the adjudication of the schedular disability rating from the adjudication of entitlement to TDIU. 24 Vet. App. 311, 315 (2011). The Court in Locklear held that "[b]ifurcation of a claim generally is within the Secretary's discretion." Id. The record does not reflect that the Veteran appealed the denial. Also, the Veteran has not contended that he is unemployable due solely to his headaches and the record does not otherwise suggest that this is the case. In VAOPGCPREC 6-96, it was noted that if the veteran asserts entitlement to a TDIU rating based in whole or in part on other service-connected disabilities which were not the subject of the appealed RO decision, the Board would lack jurisdiction over the TDIU claim except where appellate jurisdiction is assumed in order to grant a benefit, pursuant to 38 C.F.R. § 19.13(a). The only rating issue before the Board is entitlement to a compensable evaluation for migraine headaches. Given all of the foregoing, no action on the part of the Board on any TDIU issue is indicated at this time. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for PTSD is granted. Entitlement to an initial compensable rating for migraine headaches is denied. REMAND After a review of the record, the Board observes that further development is required prior to adjudicating the Veteran's remaining claims. BPH A Veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed to certain herbicide agents. In the case of such a Veteran, service connection for any of the conditions listed under 38 C.F.R. § 3.309(e), including prostate cancer, will be rebuttably presumed if they are manifest to a compensable degree at any time after service. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (2012). This presumption of service connection may be rebutted by affirmative evidence to the contrary. 38 U.S.C.A. § 1113 (West 2002); 38 C.F.R. § 3.307(d) (2012). The Veteran's period of active duty from September 1965 to September 1967 included service in the official inland waters of Vietnam from July 9, 1966 to July 30, 1966. Thus, the Veteran in this case is presumed to have been exposed to herbicides during his service in Vietnam. BPH is not a disability associated with exposure to herbicides under 38 C.F.R. § 3.307(e). Notwithstanding the fact that BPH is not subject to presumptive service connection on the basis of herbicide exposure, the Veteran could still establish service connection for this condition with competent evidence that it was incurred in service or by submitting medical or scientific evidence that it was in fact due to herbicide exposure during service. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). A March 2008 letter from the Veteran's private treating physician indicated that he had treated the Veteran since 1986 for microscopic hematuria, BPH, left kidney stone, left epididymal cyst, and low back pain. VA medical records dated from July 2010 to July 2011 show that the Veteran received intermittent treatment for BPH, hematuria, and left epididymal cyst. In a September 2010 letter, the Veteran's private treating physician again reported that he had treated the Veteran since November 1986. A November 1986 intravenous urogram had been negative, but a cystoscope taken at the same time had revealed slightly enlarged prostate gland and no bladder tumor. The physician indicated that over the course of the next 24 years, the Veteran always had a microscopic hematuria on his follow-up urological examinations. A February 2003 CT scan had shown a tiny calculus in the lower pole of the left kidney, but the physician did not believe that this tiny stone had been the cause of the Veteran's microscopic hematuria. The physician reported that on May 2010, the Veteran had the same diagnosis of slightly enlarged prostate gland and microscopic hematuria. He stated that the Veteran had informed him about his history of exposure to Agent Orange during the Vietnam War and had asked for an opinion about the cause of his microscopic hematuria. The physician opined that because of the reported document that Agent Orange could cause blood in the urine, kidney stones, and pain, he could not exclude the possibility that the Veteran's condition might be related to Agent Orange. The above opinion is speculative in nature and therefore cannot form the basis of a grant of service connection for the claimed disability. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (holding that a doctor's statement that a veteran's brain tumor "may well be" connected to Agent Orange exposure was speculative); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (noting that the use of the phrase "could not rule out" was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that medical opinions are speculative and of little or no probative value when a physician makes equivocal findings such as "the veteran's death may or may not have been averted"). The opinion, however, is evidence that indicates that BPH manifested by hematuria may be associated with herbicide exposure. Accordingly, the duty to provide the Veteran with an adequate medical opinion is triggered. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (providing that the types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits). Right Eye Disability The Veteran contends that his right eye disability is due to the exposure to arc flash from welding in service. Alternatively, he alleges that his right eye disability is due to or aggravated by a service-connected disability. (Service connection is in effect for ischemic heart disease associated with herbicide exposure and migraine headaches. Service connection for PTSD will be implemented by the AMC/RO as the result of the Board's decision herein). The duty to provide the Veteran with a medical opinion is triggered only with respect to the former theory of causation. In this regard, the Board observes that service personnel records reveal that the Veteran's military occupational specialty was that of a pipefitter apprentice. Service treatment records only show refractive error. On enlistment examination in August 1965, the Veteran had uncorrected visual acuity of 20/30 and corrected visual acuity of 20/20 in the right eye. A September 1965 treatment record indicates that the Veteran's right eye had uncorrected visual acuity of 20/50 and corrected visual acuity of 20/25. In January 1966 treatment records, the Veteran was noted to have corrected visual acuity of 20/30 and 20/40 in the right eye. On separation examination in September 1967, the Veteran had uncorrected visual acuity of 20/20 in the right eye. In a June 2009 letter, the Veteran's private physician reported that he had been treating the Veteran since 1999. Regarding the Veteran's right eye, he indicated that the Veteran currently had diagnoses of nuclear sclerotic cataracts and retinal pigment epithelium changes. VA treatment records dated from July 2010 to August 2011 show that the Veteran received intermittent treatment for his right eye. A July 2010 treatment report indicated that the Veteran had a right cataract that was not age-related macular degeneration but rather due to macular pigment irregularity of both eyes. An August 2010 treatment report revealed that the Veteran had best corrected vision of 20/30 in his right eye. In January 2011 and July 2011 VA medical reports, the Veteran was diagnosed with right cataract, hyperopia. An August 2011 medical report revealed that the Veteran had high hyperopia in both eyes. At no time did any treating provider relate the Veteran's right eye disability to his period of service or to a service-connected disability. The Veteran, however, submitted medical treatises from the Internet regarding how the intense light from arc welding could cause damage to the retina. These treatises only provided general information with respect to welding and eye disabilities and are not specific to the facts of his case. This evidence, however, is sufficient to meet the low threshold of an indication that the Veteran's right eye disability may be related to service. For these reasons, the duty to provide the Veteran with an adequate medical opinion is triggered. See McLendon, 20 Vet. App. at 83. Left Eye Disability The Veteran contends that his preexisting left eye disability was aggravated by exposure to arc flash from welding in service. He testified at his March 2013 hearing that he worked as a ship fitter during service and that his duties involved making any repairs on his ship that related to metal, plumbing, or welding. He reported that he used arc welding and wore a face shield mask for protection. However, he explained that when he looked up to see where he should be welding, the shield mask would fall open for a moment and expose him to the arc flashes. He maintained that he had incurred flash burns to his left eye during service and that this had aggravated his left eye disability. Service treatment records show that on enlistment examination in August 1965, the Veteran's uncorrected and corrected visual acuity in the left eye was 20/400. The examiner noted that the Veteran had undergone surgery for correction of left eye esotropia when he was 9 years old, and found that his left eye condition was not considered to be disabling. In a September 1965 treatment record, the Veteran was noted to only have light perception in his left eye and to be blind in the left eye. A January 1966 treatment report revealed that the Veteran had complained of decreased visual acuity. The examiner diagnosed the Veteran with hyperopia and amblyopia of the left eye. The Veteran's left eye visual acuity was found to be uncorrectable. The Veteran was recommended to go before a Medical Survey Board. The consultant, however, ultimately indicated that the Veteran met the vision standard for retention. On separation examination in September 1967, the Veteran's left eye uncorrected visual acuity was 20/200. In a June 2009 letter, the Veteran's private physician indicated that he had treated the Veteran since 1999. Regarding the Veteran's left eye, the physician found that he had diagnoses of amblyopia, macular retinal pigment epithelium clumping, exotropia secondary to amblyopia, and nuclear sclerotic cataracts. VA medical records dated from July 2010 to July 2011 show that the Veteran received intermittent treatment for his left eye disability. In a July 8, 2011 treatment report, the Veteran was found to be legally blind in the left eye with low vision. The physician made a notation of "welding related from time in service." Subsequently, in a July 27, 2011 treatment report, the Veteran's left posterior retina and peripheral retina were found to contain 2+ pigment spots. The physician made a note of "?welding" regarding the posterior retina pigment spots. No rationale, however, was provided. Therefore, the notations are inadequate to form the basis of service connection for the claimed disability. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ('[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). According to VA regulations, because refractive error of the eye is considered to be a developmental disorder, it is not subject to service connection on a direct basis, but instead, may only be subject to service connection with evidence of aggravation (superimposed injury) with resultant additional disability. See 38 C.F.R. § 3.303(c) (2012); VAOPGCPREC 82-90 (July 18, 1990), 56 Fed. Reg. 45711 (1990). Service treatment records seem to indicate that although the Veteran's left eye vision loss was not considered to be disabling on enlistment, the Veteran subsequently complained of further decreased vision loss, and his left eye visual acuity was found to be uncorrectable. VA treatment records dated in July 2011 reflect notations suggesting that the Veteran's left eye disability could be related to the welding from his period of service. The Veteran has also submitted medical treatises from the Internet regarding how the intense light from arc welding could cause damage to the retina. Given the evidence outlined above, the Veteran should now be afforded a VA eye examination with a medical opinion clarifying whether the Veteran's left eye disability was aggravated by service (superimposed injury) or is otherwise related to any incident of service, including exposure to arc flash. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Arrange for the claims file, and a copy of this remand, be made available to an examiner with appropriate expertise for review and a medical opinion on whether the Veteran's benign prostatic hypertrophy is related to herbicide exposure. The examiner is requested to address the following question: Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's benign prostatic hypertrophy manifested by hematuria is related to herbicide exposure during his military service. The examiner is advised that the Veteran is presumed to have been exposed to herbicides during his service. The examiner must discuss the September 2010 letter from the Veteran's private treating physician (Dr. C.L.) in which he contends that because Agent Orange can cause blood in the urine, kidney stones, and pain, he could not exclude the possibility that the Veteran's condition might be related to Agent Orange exposure. The examiner must provide a supporting rationale for all opinions and conclusions reached. If the examiner is of the opinion that no causal relationship exists between the claimed disorder and herbicide exposure, the rationale provided must be more than a mere conclusory reference to the fact that the claimed disorder is not a disease VA has recognized as associated with herbicide exposure pursuant to studies conducted by NAS. If the examiner believes that an opinion cannot be provided without resorting to speculation then he/she must provide a detailed medical explanation as to why this is so. 2. Schedule the Veteran for a VA eye examination to obtain a medical opinion as to whether his current right and left eye disabilities are related to his period of service. The claims file must be provided to and be reviewed by the examiner. Any tests or studies deemed necessary should be conducted, and the results should be reported in detail. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current right eye and left eye refractive error was subject to, or aggravated by, a superimposed injury (e.g., exposure to arc flash from welding) that resulted in additional disability. In regard to disabilities of the right eye and left eye other than refractive error (i.e., nuclear sclerotic cataracts, retinal pigment epithelium changes, macular pigment irregularity, macular retinal pigment epithelium clumping, hyperopia, amblyopia, etc.), the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that this disability arose during service or is otherwise related to any incident of service, to include exposure to arc flash from welding. The examiner should provide a rationale for the conclusions reached. 3. After the development requested above has been completed, the record should again be reviewed. If the benefits sought on appeal remain denied, then the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim 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). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs