Citation Nr: 1318384 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 07-34 606 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a rating in excess of 50 percent disabling for posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 10 percent for posttraumatic headaches. 3. Entitlement to a total disability rating for compensation purposes based on individual unemployability due to service connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Herman Montalvo, L.C.S.W. ATTORNEY FOR THE BOARD T.S. Willie, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to June 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision by the Houston, Texas Department of Veterans Affairs (VA) Regional Office (RO) which denied entitlement to increased evaluations for posttraumatic stress disorder, and posttraumatic headaches. The Veteran testified before the undersigned at a hearing held in February 2013. A transcript of that hearing is of record. The issues of entitlement to service connection for residuals of a traumatic brain injury, service connection for alcoholism and drug addiction claimed as secondary to PTSD, and service connection for hypertension, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to total disability evaluation based on individual unemployability due to service connected disorders is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas but not by total occupational and social impairment. 2. The Veteran has characteristic prostrating attacks due to headaches occurring on an average of once a month over the last several months. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating for posttraumatic stress disorder have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130; Diagnostic Code 9411 (2012). 2. The criteria for a 30 percent rating for posttraumatic headaches have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As explained below, the Board has determined that the evidence and information currently of record are sufficient to substantiate the appellant's claim. Therefore, no further development is required to comply with the notice or duty to assist provisions of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) [codified at 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)], or the regulations implementing it. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply, 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. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the United States Court of Appeals for Veterans Claims (Court) held that staged ratings are appropriate for an increased rating claim that is not on appeal from the assignment of an initial rating when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. Posttraumatic stress disorder posttraumatic stress disorder The Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). The Veteran appeals the denial of entitlement to an increased rating for PTSD. Save for a term when the appellant was awarded a temporary total disability rating in 2007, his posttraumatic stress disorder has been evaluated as 50 percent disabling under 38 C.F.R. § 4.130 Diagnostic Code 9411and is subject to the criteria listed under the General Rating Formula for Mental Disorders. The General Rating Formula provides a 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is warranted for 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is indicated where there is 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. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. In assessing the evidence of record, it is important to note that the global assessment of functioning score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV) at page 32). A score of 31 to 40 is assigned where there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. A score of 41-50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. A score of 51-60 is assigned where there are 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, conflict with peers or co- workers). Id. A score of 61-70 is indicated where there are 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. Id. As alluded to above, the Veteran was granted a temporary total evaluation for posttraumatic stress disorder in an April 2012 rating decision. He was granted a temporary total from May 4, 2007 to November 30, 2007, after which the scheduler 50 percent evaluation was restore. Accordingly, when reviewing the evidence applicable to the instant rating claim, the Board will consider this time frame to determine the overall impairment even though a temporary evaluation was assigned. In April 2005, the Veteran expressed that his PTSD had increased in severity. In July 2005, a VA clinical social worker stated that it was his clinical and professional opinion that the Veteran's PTSD merited a rating higher than 50 percent disabling. The Veteran reported to the social worker that he had difficulties with sleep, maintaining energy and depressed mood. The appellant also expressed that he argued with his wife over his behavior, and that for over three decades his avoidance, repression, suppression, denial and polysubstance abuse contributed to his poor memory for names or other specific information. The Veteran was admitted to a VA facility in July 2005 for stress and depression. He was having difficulty with his common law wife and stress made him unable to cope with his relationship. He admitted to be jailed in 2004 after assaulting his spouse in 2004. He stated that he drank and used cocaine when angry. He endorsed feelings of depression, and decreased sleep, interest, energy and concentration. He had suicidal ideation three days prior but denied suicidal ideation at that time. His symptoms included nightmares and a constant fear that he is going to die. The Veteran lived with his common law wife and had six children from a prior marriage with whom he had no contact with. He was unemployed but worked odd jobs through a temp agency. Mental status examination revealed that the appellant's hair was disheveled and he had minimal facial hair. His speech was clear, spontaneous, and of normal rate and volume. He was mildly depressed, and his affect was normal in range and intensity. He denied suicidal and homicidal ideation. His instant recall, remote memory and concentration were intact but recent memory impaired. He had no loose associations, hallucinations and/or delusions. The Veteran's thought content revolved around his angry feelings, he had poor insight and his judgment was impaired. A global assessment of functioning score of 45 was assigned. When examined the next day, the Veteran was doing well since his admission. His depression slightly decreased since his admission. He denied suicidal ideation but had homicidal ideations toward his common law wife. The Veteran was coherent and logical, but showed circumstantial thought when answering some questions. He had no loose associations, hallucinations and/or delusions. The Veteran's thought content revolved around his troubled relationship with his wife, he had poor insight and impaired judgment. A global assessment of functioning score of 50 was assigned. His August 2005 discharge summary noted an admission global assessment of functioning score of 45 and discharge score of 65. Examination at that time revealed he was well groomed and appeared his stated age. There was no showing of anxiety, and/or increased or decreased psychomotor activity. He had normal speech, and was alert and oriented. His thought process was coherent and logical, and his judgment and insight were fair. He denied current suicidal and/or homicidal ideations. The Veteran was afforded a VA examination in October 2005. During this examination, he reported daily nightmares and anxiety. He claimed he could not concentrate, sleep and/or work which increased his stress and strained his relationship with his common law wife. The Veteran had been unemployed since August 2003 but was trying to find work. He did admit to performing occasional day labor. He reported no social contacts except for his spouse whom he was dependent on. A global assessment of functioning score of 50 was assigned. The Veteran's level of symptomatology and social and occupational functioning was consistent with prior levels. The examiner found no obvious change from January 2004 when a 50 percent rating was granted, despite the recent hospitalization. In August 2006, the Veteran stated that he unable to secure and remain employed because of his PTSD symptoms. He stated that he continued to struggle with depression, anxiety, nightmares, anhedonia and sleep. According to the Veteran, he used avoidance (instead of alcohol/illicit drugs) to minimize his difficulty with socialization and to avoid confrontations. When presented at the Vet Center in November 2006, evaluation revealed he was neat in appearance, appropriate in speech, friendly and oriented. His memory function was normal, judgment was good, motor activity was relaxed and intelligence was above average. There was no evidence of thought disorder. He also denied suicidal and/or homicidal thoughts. The Veteran stated in October 2007 that although he was employed, he required much supervision and support. Outpatient treatment records in 2008-2009 revealed GAF scores ranging from 60 to 62. At a November 2010 VA examination, it was noted that the Veteran had gained some stability for the last three and a half years working as a housekeeper. He continued to have PTSD symptoms and problems with depression, irritability, sleep, increased arousal, diminished participation in activities, avoidance, detachment, hypervigilance, exaggerated startle response, distressing dreams, panic attacks, isolation, anxiety and loss of concentration. He was divorced and lived with his girlfriend, and reported having on contact with his children. His relationship with his girlfriend was described as "somewhat productive, "and his relationship with his supervisor and coworkers were described as a good. At that time, he had not lost any time from work. Examination revealed his orientation was within normal limits, and his appearance and hygiene were appropriate. He was anxious and his mood depressed. He had a sense of worthlessness and diminished ability to think or concentrate. Communication and speech were within normal limits, but he showed some difficulty understanding complex commands. He was unable to multi task because this along with his loss of memory. His panic attacks reportedly occurred less than once a week but rather about once a month. The Veteran had a distrust of people. He was without a history of delusions but a hallucination history was present. He indicated that he sometimes heard voices but could not identify them. Compulsive behavior was absent. His thought processes were appropriate and he was able to understand directions. His judgment was deemed not impaired and abstract thinking was normal. He had a mild degree of memory loss. Suicidal and homicidal ideation was absent. The VA examiner found that mentally the Veteran did not have difficulty performing the activities of daily living but that he had difficulty establishing and maintaining effective work/school and social relationships. The examiner found that the Veteran's impairment was mild or transient but caused occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. According to the examiner, the Veteran had difficulty maintaining effective family role functioning because he had "no family." He was found to have occasional interference with recreation or leisurely pursuits because he occasionally liked to listen to music and watch television, and he went to alcoholics anonymous regularly. The Veteran did not pose any threat or danger or injury to self or others. His prognosis was guarded. A global assessment of functioning score of 68 was assigned. In October 2012, the Veteran's employer issued him a formal memo to inform him that his sick leave usage was unacceptable. In a separate statement, the Veteran expressed that he struggled with his PTSD and his work performance reflected that struggle. Although he was employed as a housekeeper, he maintained that it was extremely difficult to continue this employment. He stated that he wanted to remain working but his symptoms made it more and more difficult. During his February 2013 hearing, the Veteran testified that he had difficulty communicating with people to include when at work. He related his anxiety was hard for him and sometimes required that he leave his home. According to the Veteran, he was unable to stop his anger and he feared that he may hurt someone. The Veteran related that he had issues with his coworkers at times. He recalled an altercation with a coworker which resulted in the transfer of the coworker. He had panic attacks that continued up to three days and difficulty sleeping. He expressed having suicidal ideation and he described a prior attempt at suicide. Although he was in a relationship, the Veteran stated that they did not live like man and wife. Rather, they slept in separate rooms. He also reported that he had just recently come in contact with his children after 20 years of no communication. He expressed that he had been away from his relatives for 30 years. He reported that he used up all of his sick leave because of his migraine headaches and PTSD. A VA licensed clinical social worker also testified that he had been working with the Veteran for about eight years and that his global assessment of functioning ratings have always been exceedingly high. He stated that the Veteran was troubled and was a man who continued to have difficulty sleeping, interacting socially and interacting vocationally. He further stated that there were instances with the Veteran's many symptoms that made it difficult for him to continue with full-time employment. The social worker noted that the Veteran had no social life and he hunkered down in a dark room. Based on the evidence of record, the Board finds that the Veteran's posttraumatic stress disorder is the cause of occupational and social impairment with deficiencies in most areas, such as judgment, thinking, family relations, work and mood. In this regard, the Veteran reports suicidal and homicidal ideations, depressed mood, continuous anxiety, panic attacks, occupational difficulty, anger problems, social avoidance, concentration problems and sleep impairment. He has poor insight and impaired judgment at times, and a history of hallucinations. The evidence also shows that he has the inability to establish and maintain effective relationships. He has been married, divorced, and did not live with his current girl friend as man and wife. He reports a history of no contact with extended family for many years, and only recently came in contact with his children after decades of no communication. These findings justify an evaluation of 70 percent disabling during the applicable time frame. While an examiner's classification of the level of a psychiatric impairment, by words or by a global assessment of functioning score, is to be considered, that classification is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126. Here, it is notable that for the period considered in this appeal the Veteran's global assessment of functioning scores ranged from 45 to 65, denoting mild to serious impairment. In the view of the Board, the global assessments of functioning scores are consistent with the Veteran's PTSD symptomatology and the assignment of a 70 percent rating. The Board finds, however, that entitlement to an evaluation higher than 70 percent disabling is not warranted. Although the Veteran has occupational difficulties, he continues to remain employed. Despite his social impairments, he also remains in a relationship and has recently come in contact with his children after 20 years of no communication. Examinations reveal he is oriented. Although he has suicidal and homicidal ideation at times, his ideations have not been persistent and he was found not to be a threat or danger to self or others. It is also noted that while the Veteran was found to have impaired judgment, poor insight and some degree of memory loss, the above have not been consistently shown. Rather, when examined in November 2010 his judgment was not impaired, thought processes were appropriate, and abstract thinking was normal. Such findings do not warrant a 100 percent evaluation when all the other manifestations are considered. Mauerhan, 16 Vet. App. at 443. It is also noted that, after thorough examination, the November 2010 VA examiner found that the Veteran's impairment was mild or transient but caused occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. The Board acknowledges the Veteran's assertions that his disability is more severe than evaluated. The Veteran is competent to report his symptoms and he has presented credible testimony in this regard. The Board finds, however, that neither the lay nor medical evidence demonstrates that the criteria for a 100 percent evaluation have been met. In sum, the Veteran's symptoms are more characteristic of a disability picture that is contemplated by a 70 percent rating and no more during this time period. Posttraumatic migraine headaches The Veteran appeals the denial of a rating higher than 10 percent for posttraumatic headaches. The Veteran's disability has been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a 10 percent rating is in order where there is evidence of characteristic prostrating attacks due to migraines that average one every two months lasting over several months. A 30 percent rating is warranted for migraine headaches with 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. In April 2005, the Veteran expressed that his migraine headaches occurred four to five times a week and required bedrest sometimes lasting 24 hours. At an October 2005 VA examination, the Veteran reported his headaches were not treated with medication. He had headaches at least five days week that were constant. Occasional vomiting was associated with the headaches. He was unemployed and reported that he had not worked since 2004 because of his headaches. Examination revealed he was neurologically intact. His cranial nerve was intact, and no abnormal or pathological reflexes elicited. Posttramatic headaches which do not interfere with employment, since he is an unskilled laborer, and interfere with his performance in the heat and the elements of everyday life were diagnosed. It was noted in August 2006 that the Veteran had been tried on medications for his headaches. In an August 2006 statement, the Veteran reported having severe daily headaches which painfully radiated down his neck and shoulders. In October 2006, he stated that he suffered from daily migraines and was required to carry tablets for the onset of his migraines. Outpatient treatment records in 2009 show continued reports of daily headaches. In May 2009, it was noted that the headaches did not appear to have impaired the Veteran's mental capacity, judgment or physical abilities relative to activities of daily living, general activity or with the performance of his duties. The examiner related that it also appeared that the Veteran lived with the headaches and led a relatively normal private and professional life. In the November 2010 VA examination, the Veteran described his headaches as a 10 on a 1 to 10 scale. He reported headaches on average seven times a week which lasted for 24 hours. Tension headaches were diagnosed. The effect of headaches on the Veteran's usual occupation and daily functioning, according to the examiner, was judged to be an occasional disorientation and difficulty functioning. At the November 2011 VA examination the Veteran's headaches were described as frontal and of the left side back of head with radiation all over the head. The headaches occurred when laying supine, sitting and standing. With the headaches, the appellant was able to work but required medication. The Veteran reported an average of four headaches per week which lasted for seven days. Post traumatic headaches were diagnosed. The headaches were noted to slow the Veteran down occupationally but he continued. The examiner found no effect on the Veteran's daily activities. In January 2012, the VA examiner stated that the Veteran's headaches were not prostrating and that he could continue ordinary activity after short rest. During his February 2013 hearing, the Veteran reported that he had headaches that radiated all the way down to his face and jaw. He testified that he worked through his headaches because he had to function. The light bothered his eyes and he vomited at times. According to the Veteran, he had about three headaches a week which lasted sometimes for a week. He reported that he used up all of his sick leave because of his migraine headaches and PTSD, and that he lost about half his work week due to symptoms of the headaches and PTSD. The VA social worker testified that the appellant's headaches affected his entire life. In light of the evidence summarized above, the Board finds that a 30 percent rating is warranted. In this regard, the Veteran reports headaches about three to four times a week which last up to a week at times. The headaches affect his entire face and head area, and were sometimes accompanied with light sensitivity and nausea. He reports having days when he can do nothing. The evidence reflects that his headaches continue to be a significant problem and have caused him to be absent from work. The Veteran has presented credible testimony regarding the severity of his headaches. While the Board is mindful of the opinions of the VA examiners, his social worker has credibly opined that the appellant underreports his symptoms. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that his headache symptoms approximate characteristic prostrating attacks occurring on an average once a month over the last several months. The Board, however, notes that an evaluation higher than 30 percent is not warranted in this case. In this regard, the evidence does not show that the Veteran's headaches are manifested by prolonged attacks productive of severe economic inadaptability. While the record reflects persistent headaches that are a problem for the Veteran, there is no indication in the evidence of severe economic inadaptability. Rather, despite his symptoms, the Veteran continues to work. The Board acknowledges the Veteran's assertions that his disability is more severe than evaluated to include his reports of daily headaches and occupational difficulty. The Veteran is competent to report his symptoms and has presented credible testimony. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds, however, that neither the lay or medical evidence demonstrates that the criteria for a 50 evaluation have been met. All Claims The Board has considered whether the Veteran's disability presents 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 extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). There are no exceptional or unusual factors with regard to the Veteran's disability. 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 evaluation for that service-connected disability is 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 levels and symptomatology, and other codes provide for consideration of greater disability and symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extra-schedular consideration is not warranted. In reaching this decision, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b). ORDER Entitlement to a rating of 70 percent for PTSD is granted, subject to the rules and payment of monetary benefits. Entitlement to a rating of 30 percent for posttraumatic headaches is granted, subject to the rules and payment of monetary benefits. REMAND The law provides that a total disability evaluation based on individual unemployability due to service connected disorders may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held that a claim for individual unemployability is part of an increased rating claim when such claim is raised by the record. The Veteran has expressed that his posttraumatic headaches and posttraumatic stress disorder symptoms make it difficult for him to work. It is also noted that during this appeal, the Veteran was, at times, unemployed and he contends that he was unable to work because of his headaches and PTSD. A claim of entitlement to a total disability evaluation based on individual unemployability due to service connected disorders is raised by the record. Accordingly, the Board has jurisdiction over this issue. However, in the present case, additional development is required before the claim can be adjudicated, including addressing the issues referred above, and providing appropriate notice and assistance pursuant to the Veterans Claims Assistance Act of 2000 (VCAA) and adjudicating the claim. Accordingly, the case is REMANDED for the following action: 1. After fulfilling any duties to assist and notify the appellant under the VCAA the RO must adjudicate the inextricably intertwined claims of entitlement to service connection for residuals of a traumatic brain injury, service connection for alcoholism and drug addiction secondary to PTSD, and service connection for hypertension. The Veteran is hereby notified that should any of these claims be denied, the Board will only exercise appellate jurisdiction over them after a timely appeal is perfected. 2. The RO must ensure that all VCAA notice and assistance obligations are satisfied concerning the claim for total disability evaluation based on individual unemployability due to service connected disorders. This specifically includes obtaining a VA medical or vocational rehabilitation opinion addressing the question whether it is at least as likely as not that the Veteran is unable to obtain and maintain substantially gainful employment as a result of his service-connected disabilities alone. 3. The Veteran is to be notified that it is his responsibility to report for any examination that may be ordered and to cooperate in the development of his claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for an ordered examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 4. Thereafter, the RO must adjudicate the claim for a total disability evaluation based on individual unemployability due to service connected disorders to include consideration of the private opinions of record. If the benefit is not granted to appellant's satisfaction, the claim of entitlement to a total disability evaluation based on individual unemployability due to service connected disorders must be returned to the Board following appropriate action. No opinion as to the outcome is intimated by the action taken herein. 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). ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs