Citation Nr: 1324108 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 11-23 907 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to a disability rating in excess of 40 percent prior to May 17, 2010 and a compensable disability rating as of May 17, 2010 for residuals of a fractured skull and concussion. 2. Entitlement to an initial disability rating in excess of 50 percent for service-connected posttraumatic headaches. 3. Entitlement to an initial disability rating in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his son ATTORNEY FOR THE BOARD B. Berry, Counsel INTRODUCTION The Veteran served on active duty from October 1982 to January 1990. These matters come to the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in February 2009 and October 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. The Veteran testified during a hearing before the undersigned Veterans Law Judge in February 2012. A transcript of the hearing is of record. The Board remanded these matters in April 2012 for further evidentiary development. The RO continued the denial of the claims as reflected in the January 2013 supplemental statement of the case (SSOC) and returned these matters to the Board for further appellate consideration. During the pendency of the appeal, the RO granted an increased rating of 50 percent for posttraumatic headaches, effective May 17, 2010 in a January 2013 rating decision. The RO determined in the rating decision that this grant was considered a total grant of benefits sought on appeal as the 50 percent disability rating was the maximum disability rating available for migraine headaches under 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board notes that the initial increased rating for posttraumatic headaches stems from the increased rating claim for residuals of a fractured skull and concussion with headaches in November 2008. As the effective date of the separate 50 percent disability rating for posttraumatic headaches does not go back to the date of the increased rating claim filed in October 2008, it is not considered a full grant of benefits. Furthermore, the evidence of record does not reveal that the Veteran specifically limited himself to a 50 percent disability rating. If the Veteran does not specifically limit himself to a particular rating, he is presumed to be seeking the highest rating available for a disability, i.e., 100 percent. AB v. Brown, 6. Vet. App. 35, 38 (1993). Based on the foregoing, this issue is still before the Board for adjudication. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran's service-connected residuals of a fractured skull is characterized by prostrating headaches that occur on average less than one in two months, no evidence of purely neurological disabilities and a level of impairment less than 3 for all facets of cognitive impairment and other residuals of TBI prior to May 10, 2010. 2. The preponderance of the evidence reveals that the Veteran's service-connected residuals of a fractured skull is manifested by a level of impairment of 0 in all facets or cognitive impairment and other residuals of TBI with no purely neurological disabilities and separate disability ratings for posttraumatic headaches and PTSD as of May 10, 2010 3. A 50 percent disability rating for posttraumatic headaches is the maximum schedular rating that can be assigned for this disability under Diagnostic Code 8100 and the preponderance of the evidence shows that no other Diagnostic Code would provide a basis to grant a higher evaluation for the given the nature and location of posttraumatic headaches. 4. The preponderance of the evidence reveals that the Veteran's service-connected PTSD is manifested by deficiencies in most areas of social functioning and occupational functioning including recurrent recollections of the event, avoidance of thoughts and situations that arouse recollections of the event, depressed mood, diminished interest in significant activities, impaired impulse control to include irritability and outbursts of anger, difficulty concentrating, hypervigilence, anxiety and panic attacks, the Veteran was assigned a GAF score that ranged from 45-65. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 40 percent for service-connected residuals of a fractured skull prior to May 17, 2010 have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8045 (2012). 2. The criteria for a compensable disability rating for service-connected residuals of a fractured skull as of May 17, 2010 have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8045 (2012). 3. The criteria for an initial disability rating in excess of 50 percent for posttraumatic headaches have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). 4. The criteria for an initial disability rating in excess of 70 percent for service-connected PTSD have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). In this case, the duty to notify was satisfied through a letter dated in November 2008, which preceded the rating action on appeal. VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, VA treatment records, Social Security disability records, VA examination reports dated in December 2008, August 2009, July 2010, April 2012 and January 2013, lay statements from the Veteran and his family and a transcript of the February 2012 Board hearing. The VA examination reports dated in December 2008, August 2009, July 2010, April 2012 and January 2013 reflect that the examiners conducted a review of the Veteran's claims file in addition to eliciting a history of the Veteran's service-connected disabilities and conducting an evaluation of the issues on appeal. The examiners documented the claimed symptoms and objective symptoms found on evaluation of the Veteran. Therefore, the VA examinations are adequate for rating purposes These claims were previously remanded in April 2012 in order to obtain outstanding Social Security disability records and to schedule the Veteran with a VA examination to evaluate the current severity of his service-connected disabilities on appeal. The claims file contains the Veteran's Social Security disability records and VA examination reports dated in April 2012 and January 2013 that document the current severity of the Veteran's service-connected residuals of fractured skull and concussion, posttraumatic headaches and PTSD. Accordingly, the Board finds that there has been substantial compliance with the April 2012 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Based on the foregoing, the record presents no basis for further development to create any additional evidence to be considered in connection with the issues currently under consideration. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claims on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C.A. § 5107(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Residuals of Fractured Skull The Veteran filed an increased rating claim for his service-connected residuals of fracture skull in November 2008. The Veteran's residuals of skull fracture and concussion is currently evaluated under Diagnostic Code 8045, which evaluates traumatic brain injury (TBI). The criteria for evaluating TBI under Diagnostic Code 8045 were amended effective October 23, 2008. 38 C.F.R. § 4.124a (effective October 23, 2008), 73 Fed. Reg. 54,693 (Sept. 23, 2008). The revised regulation describes three main areas of dysfunction listed that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2012). Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is to be evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Emotional/behavioral dysfunction are evaluated under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, any emotional/behavioral symptoms due to TBI should be assessed under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Physical (including neurological) dysfunction should be evaluated based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. Residuals that are not listed here that are reported on an examination should be evaluated under the most appropriate diagnostic code. Each condition should be assessed separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The regulation directs VA to consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and the highest level of impairment labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100-percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled ""Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. During the pendency of this appeal, the RO increased the disability rating assigned to the Veteran's residuals of a fractured skull and concussion from 10 percent to 40 percent, effective November 7, 2008 and then reduced it to noncompensable (0 percent) effective May 17, 2010 as the Veteran's posttraumatic headaches and PTSD as residuals of fractured skull were evaluated separately. The Board has considered whether the Veteran is entitled to a higher disability rating under the assigned stages of this appeal. Additionally, the Board has considered whether additional staging is appropriate. For reasons discussed in more detail below, the Board finds that the stages created by the RO are appropriate in light of the competent medical evidence of record and that there is no competent evidence that the Veteran's service-connected disability underwent further increases in severity during this appeal sufficient to warrant additional staged ratings. Prior to May 17, 2010 In evaluating the Veteran's residuals of fractured skull and concussion with headaches under Diagnostic Code 8045, the Board finds that an assignment of 2 under the sections of memory, attention, concentration and executive functions is warranted. In this regard, the evidence of record shows that the Veteran has mild memory problems and some difficulty with concentration. His wife has to remind of tasks and he will sometimes go to the wrong place, but he figures it out himself and recovers. The Veteran also reported in the December 2008 VA examination that he has been forgetful at work. For example, he forgot to put down his facial mask when he was welding (which he has years of experience) and he experienced some minor skin burns. The Veteran often second guesses himself at work; such as, thinking he is heading in the wrong direction when he is not. Although he has made some minor mistakes at work due to concentration and memory issues, he is usually able to correct his errors and he does not believe that his supervisor was aware of him making mistakes. Thus, the Veteran's problems with memory, attention, concentration and executive functions appear to result in mild functional impairment based on objective evidence on testing prior to May 17, 2010. The evidence of record reveals that an assignment of an impairment level of 0 under the sections of judgment; motor activity; visual and spatial orientation and communication is appropriate prior to May 17, 2010. The evidence of record reveals that the Veteran's judgment was within normal limits and he did not have any problems with motor activity. The evidence shows that the Veteran is able to communicate by and comprehend spoken and written language. With respect to visual and spatial orientation, the evidence shows that the Veteran occasionally goes to the wrong place; however, it appears that this is due to his mild memory and concentration problems and not evidence of a visual or spatial orientation issue. An October 2009 addendum to the August 2009 VA examination revealed that the Veteran's visual spatial orientation was within normal limits. With respect to social interaction and neurobiological impairment, the evidence of record indicates that prior to May 17, 2010, the Veteran had some problems with anger and irritability as he had arguments with his boss and co-worker's at his last job, which ended in December 2008. See VA examination dated in July 2010. The Veteran reported in the August 2009 TBI examination that he was laid off due to economic factors. The medical evidence shows that the Veteran management problems due to the frontal lobe injury and that he is upset quite a bit and he is moderately irritable. A March 2010 VA treatment record indicates that his irritability his interpersonal relationships and that his relationship with his wife is strained. Accordingly, the evidence indicates that the Veteran's social interactions are occasionally inappropriate and his neurobiological effects occasionally interfere with workplace interaction due to his issues of anger and irritability and warrants an assignment level of 1 for social interaction and neurobiological impairment. The preponderance of the evidence shows that the Veteran is occasionally disoriented to place, one of the four aspects of orientation (person, time, place or situation). In this regard, the Veteran will sometimes drive to the wrong location and his wife will sometimes have to correct him that he is heading in the wrong direction. The medical evidence of record consistently shows that the Veteran is oriented to person time and situation. Thus, the assignment of a 1 for the impairment level in orientation is appropriate. With respect to subjective symptoms, the evidence of record shows that the Veteran experiences moderate to severe daily headaches, occasional dizziness and fatigue. The overall evidence indicates that the Veteran's subjective symptoms do not interfere with his work or other activities such as chores, going to the gym or being active with his children. However, these symptoms appear to mildly interfere with some activities of daily living and family relationships. Thus, the Veteran's subjective symptoms more closely approximate an impairment level of 1. There is no evidence that the Veteran has a persistently altered state of consciousness. Thus, the Veteran's residuals of fractured skull with concussion do not approximate a total level of impairment for consciousness. As the highest level assigned was not three or above in any of the facets, the Veteran is not entitled to a disability rating in excess of 40 percent under Diagnostic Code 8045 prior to May 17, 2010. The Board has also considered whether the Veteran is entitled to a separate compensable disability rating under Diagnostic Code 8100 for his posttraumatic headaches prior to May 17, 2010. Under Diagnostic Code 8045, residuals of traumatic brain injury may be separately rated when there is a distinct diagnosis, such as post-traumatic headaches. Diagnostic Code 8100 provides that migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated as 10 percent disabling. A 30 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). VA regulations do not define "prostrating;" nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "prostration" is defined as "complete physical or mental exhaustion." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which "prostration" is defined as "extreme exhaustion or powerlessness." In this case, the evidence of record shows that the Veteran has daily moderate to severe headaches. These headaches are without nausea or aura. The overall medical evidence indicates that the Veteran's headaches did not interfere with his work prior to May 17, 2010. A March 2010 VA treatment reveals that the Veteran at times will go to bed earlier in the evening or lay in bed when his headaches are particularly bad. However, he reported that the pain does not impact his activity levels as he still works out regularly and is active with his sons. An April 2010 VA treatment record also shows that the Veteran's pain does not limit his ability to engage in pleasurable activities. The Board finds that the preponderance of the evidence shows that the Veteran does not have prostrating attacks averaging one in two months over a several month period. Accordingly, the Veteran is not entitled to a compensable rating under Diagnostic Code 8100 prior to May 17, 2010. As of May 17, 2010 In evaluating the Veteran's residuals of fractured skull and concussion under Diagnostic Code 8045 as of May 17, 2010, the Board finds that an assignment of 0 under the sections of memory, attention, concentration, executive functions; judgment; social interaction; orientation; motor activity; visual spatial orientation; neurobiological effects and communication. In this regard, the Veteran's symptoms of memory loss, attention and concentration problems, judgment, social impairment and neurobiological impairment are considered in the Veteran's 70 percent disability rating for PTSD under Diagnostic Code 9411. The Board finds that assessing these symptoms under Diagnostic Code 8045 would constitute pyramiding as it would consider the same symptoms that are evaluated in the separate rating for PTSD. See 38 C.F.R. § 4.14 (the evaluation of the same disability under various diagnoses is to be avoided and the evaluation of the same manifestation under different diagnoses are to be avoided). Accordingly, to avoid violating the rule of pyramiding, the Board will not evaluate those same symptoms under Diagnostic Code 8045 and therefore, a level of impairment of 0 is assigned for those sections. Furthermore, the evidence of record indicates that the Veteran's motor activity and visual spatial orientation are normal. The Veteran is able to communicate by and to comprehend spoken and written language. The evidence also shows normal consciousness. Regarding the Veteran's subjective symptoms, the Veteran's headaches are separately evaluated under Diagnostic Code 8100 as analogous to migraine headaches as of May 17, 2010. The Board will not evaluate the Veteran's headaches under subjective symptoms as this would constitute pyramiding. The other subjective symptoms include occasional dizziness and frequent fatigue. The Veteran reported in the July 2010 VA examination that he takes a nap almost daily for ten minutes. The evidence indicates that the Veteran frequently feels dizzy and it is not precipitated by anything in particular. He described the sensation as analogous to feeling lightheaded versus vertigo. As the evidence indicates that the Veteran does not have three or more subjective symptoms, his subjective symptoms more closely approximate an impairment level of 0. Based on the foregoing, the preponderance of the evidence shows that the highest level of impairment was not one or above in any of the facets as of May 17, 2010. Therefore, the Veteran is not entitled to a compensable disability rating under Diagnostic Code 8045 as of May 17, 2010. The discussion above reflects that the Veteran's condition is manifested by some impairment of cognition, judgment and social interaction. These are precisely the symptoms contemplated by 38 C.F.R. § 4.123, pursuant to which his condition is rated. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). Posttraumatic Headaches The Veteran was assigned a separate disability of 50 percent for posttraumatic headaches as of May 17, 2010. This is the maximum disability rating available for headaches. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board has carefully reviewed the rating schedule and finds no other Diagnostic Code that would provide a basis to grant a higher evaluation for this disorder given the nature and location of his disability. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence); 38 C.F.R. § 4.20 ("When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous."). In essence, the Veteran currently has the highest possible schedular rating provided for headaches. The rating criteria outlined in Diagnostic Code 8100 consider the symptom type and frequency due to the Veteran's service-connected headache disability (i.e., frequently prostrating and prolonged). Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun, 22 Vet. App. at 111. PTSD When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (2012). The Veteran's service-connected PTSD is presently assigned a 70 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). PTSD is rated pursuant to the General Rating Formula for Mental Disorders. Id. Under the General Rating Formula for Mental Disorders, a 70 percent rating is prescribed 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is prescribed for 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 determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Global Assessment of Functioning (GAF) Scale is used to report the clinician's judgment of the individual's overall level of functioning. The GAF Scale is to be rated with respect only to psychological, social and occupational functioning. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994 (DSM-IV), at 44. GAF scores range from 1-100 with the higher numbers representing higher levels of functioning. A GAF score ranging between 41 and 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, occasional panic attacks) or serious impairment in social, occupation or school functioning (e.g., no friends, unable to keep a job). A GAF score between 51 and 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupation, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score ranging from 61-70 reflects some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupation, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well with some meaningful relationships. The relevant medical evidence of record consists of VA examination reports dated in July 2010, April 2012, January 2013, VA treatment records, and SSA disability records. Furthermore, the claims file contains lay statements from the Veteran and a transcript of the February 2012 Board hearing. The Board finds that this evidence, the most pertinent of which is summarized below, shows that the Veteran's condition as a whole more closely approximates the current criteria for a 70 percent disability rating. In this regard, the evidence of record is negative for characteristics such as gross impairment in thought processes or communication; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The Board notes that a July 2010 VA examination report reveals that the Veteran's thought process was circumstantial and a June 2010 VA treatment record reveals that the Veteran's thought process was somewhat tangential. Nonetheless, the preponderance of the medical evidence of record reveals that the Veteran's thought process was linear and logical and his speech was spontaneous, clear and coherent throughout the appeal period. The overall medical evidence reflects that the Veteran was oriented to person, place, time and situation. The Veteran's PTSD does not result in hallucinations or delusions. The Veteran has mild attention and concentration issues resulting in mild short term memory problems. Longer term memory was normal. The VA examiner in January 2013 documented that the Veteran was a good historian of current psychosocial stressors, including dates and details. He was also able to report the plot of a recent move he saw in quite a bit of detail. The evidence reflects that the Veteran has fair impulse control and significant problems with anger and irritability. The evidence of record also does not indicate that the Veteran is in persistent danger of hurting himself or others. In this regard, the medical evidence of record shows that the Veteran had consistently denied homicidal thoughts. The July 2010 VA examination reveals that the Veteran had suicidal ideation of a passive nature. A September 2010 VA treatment report notes that the Veteran has had transient suicidal ideation, but he denied having any active thoughts at that point in time and he was able to verbalize why he would not hurt himself. Thus, although there is evidence of recurrent suicidal ideation, the overall evidence suggests that the Veteran does not have any intention of carrying out these thoughts and accordingly, the Board concludes that the Veteran is not in persistent danger of hurting himself. The Veteran is able to perform activities of daily living. Specifically, the Veteran has reported that he does most of the cooking and some cleaning. He also enjoys doing yard work. He does the household shopping and errands, because his wife works, but he sometimes forgets to buy things on the list. The Veteran has testified that he sometime gets lost when he is driving. The evidence of record also reveals that the Veteran does not have any problems with grooming and personal hygiene. Furthermore, the evidence shows that the Veteran's symptoms do not result in total occupational and social impairment due to his PTSD. With respect to social impairment, the Board finds that the evidence indicates his PTSD results in severe social impairment. The Veteran has been married twice. He has been married to the same woman for approximately 23 years and he has three children. The Veteran's relationship with his wife has ranged from good to terrible during the appeal. The Veteran reported in the January 2013 VA examination that it is tough for his wife to deal with his issues. She feels like she has to take care of him and it is not fair that he cannot reciprocate and take care of her. He is often irritable and snaps at his children. He reported that that his relationship with his oldest son is difficult, but he has a good relationship with his younger two children. The Veteran does not get along with his extended family and he does not have any friends. He does see his wife's family. His hobbies include working out. The overall evidence of record reveals that the Veteran also has severe occupational impairment due to his PTSD symptoms of anger and irritability. When the Veteran was working his actual work performance was good, but he had significant problems as a result of his anger and irritability. He would lose his temper, which would result in arguments with his boss and co-workers. He reported that he was fired from his last three jobs due to anger and irritability. During the appeal period, the Veteran was part of VA's Compensated Work Therapy (CWT) program. This was a full time program and he did anything that had to do with construction. The Veteran's GAF score ranged from 45 to 65 throughout the entire appeal period. This range in GAF score reveals mild to serous symptoms with mild to serious difficulty in social and occupational activities. Thus, the Veteran's GAF score is consistent with the Veteran's overall disability picture including symptoms reported at the VA examinations and discussed in the lay evidence indicating that the Veteran's disability picture more closely approximates the current 70 percent disability rating. The Board has considered whether staged ratings are appropriate. The evidence of record shows that the Veteran's PTSD symptoms have not fluctuated materially as to warrant a 100 percent rating at any time during the course of this appeal. As such, a staged rating is not warranted. The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected psychiatric disability. The Veteran's disability is manifested by impairment in social and occupational functioning. The rating criteria contemplate these impairments; hence, referral for consideration of an extraschedular rating is not warranted. Thun, 22 Vet. App. at 111. ORDER Entitlement to a disability rating in excess of 40 percent prior to May 17, 2010 and a compensable disability rating as of May 17, 2010 for residuals of a fractured skull and concussion is denied. Entitlement to an initial disability rating in excess of 50 percent for service-connected posttraumatic headaches is denied. Entitlement to an initial disability rating in excess of 70 percent for service-connected PTSD is denied. ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs