Citation Nr: 1325531 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 10-30 747 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to a rating higher than 30 percent for posttraumatic stress disorder (PTSD) with dysthymia prior to January 10, 2007, and a rating higher than 50 percent thereafter. 2. Entitlement to a rating higher than 20 percent for diabetes mellitus type II. 3. Entitlement to a rating higher than 10 percent for headaches due to a concussion (traumatic brain injury or TBI). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from November 1949 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from two rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. In November 2006, the RO denied increased ratings for the Veteran's service-connected PTSD with dysthymia and diabetes mellitus type II. Notably, the Veteran submitted a statement in January 2007 in which he stated that he had received the November 2006 rating decision. He explained that he had been scheduled for an examination as part of that claim, but was unable to attend due to a scheduled hip surgery. Despite informing the RO of this, his examination was not rescheduled. Therefore, he sought to have his claim "reopened." Although the RO interpreted the Veteran's statements as new claims for increased ratings, the Board has determined that they are actually a notice of disagreement (NOD) with the November 2006 rating decision. See 38 C.F.R. § 20.201 (communication expressing dissatisfaction with RO decision and desire to contest the result constitutes a NOD; special wording not required); Palmer v. Nicholson, 21 Vet. App. 434, 437 (2007) (VA has always been, and will continue to be, liberal in determining what constitutes a notice of disagreement). A May 2010 rating decision granted a 50 percent evaluation for PTSD with dysthymia from January 10, 2007. Therefore, the issue has been recharacterized as above. In March 2010, the RO denied an increased rating for headaches due to a concussion (TBI). Notably, the Veteran had a similar claim denied in a February 2009 rating decision. A written submission from the Veteran was received in September 2009. However, he merely stated that he wished to apply for "SC consideration" for his TBI, which the RO interpreted as a new claim for an increased rating. Although the September 2009 submission was received within one year of the February 2009 denial, it is not an NOD. While a liberal standard is applied in determining whether a communication constitutes an NOD, the communication in question must at least refer to the rating decision in question and be in terms that can be reasonably construed as expressing disagreement or dissatisfaction with the determination and a desire for appellate review. 38 C.F.R. § 20.201; Stokes v. Derwinski, 1 Vet. App. 201, 203 (1991); see also Beyrle v. Brown, 9 Vet. App. 24, 28 (1996). The Veteran was scheduled for a videoconference hearing in June 2013. However, he did not appear for that hearing, and subsequent correspondence indicates that he wished to cancel his hearing request. See 38 C.F.R § 20.702(e) (2012). A portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. Prior to January 10, 2007, the Veteran's PTSD with dysthymia was not manifested by abnormal speech, panic attacks, difficulty in understanding complex commands, memory impairment, impaired judgment, or impaired abstract thinking. 2. From January 10, 2007 to January 30, 2013, the Veteran's PTSD with dysthymia was manifested by suicidal ideation, but was not manifested by obsessive behavior, speech abnormalities, panic attacks, spatial disorientation, or periods of violence; he was able to maintain proper hygiene and effective relationships with his family and others. 3. From January 31, 2013, the Veteran's PTSD with dysthymia was manifested by suicidal ideation and occupational and social deficiencies in most areas; it was not manifested by persistent delusions or hallucinations, grossly inappropriate behavior, an intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for basic concepts such as his own name. 4. Diabetes mellitus type II is not treated or managed with a regulation of activities. 5. Headaches are not manifested by prostrating attacks, and nausea, vomiting, and visual disturbances were not present for most of the appeal period. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for PTSD with dysthymia prior to January 10, 2007 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating in excess of 50 percent for PTSD with dysthymia from January 10, 2007 to January 30, 2013 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a 70 percent disability rating for PTSD with dysthymia have been met from January 31, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). 4. The criteria for a rating higher than 20 percent for diabetes mellitus type II have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.119, Diagnostic Code 7913 (2012). 5. The criteria for a rating higher than 10 percent for headaches due to a concussion have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Codes 8045, 8100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Prior to the initial adjudication of the Veteran's claims, letters dated in May 2006 and January 2010 were sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate his claims; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist him in obtaining evidence, but that it was his responsibility to provide VA with any evidence pertaining to his claims. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). B. Duty to Assist The Veteran's service treatment records, VA treatment records, and lay statements have been associated with the claims file. The Veteran was also afforded VA examinations. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; and record the relevant findings for rating the Veteran's PTSD, diabetes, and headaches. VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claims. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Ratings A. Applicable Law Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The U.S. Court of Appeals for Veterans Claims (Court) has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). B. PTSD with Dysthymia The Veteran's PTSD with dysthymia is rated under Diagnostic Code 9411. He is assigned a 30 percent rating prior to January 10, 2007, and a 50 percent rating thereafter. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is assigned 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 that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the Veteran's own occupation or name. Id. The record also contains Global Assessment of Functioning (GAF) scores. As described in the Fourth Edition of the American Psychiatric Association's DIAGNOSTIC AND STASTICAL MANUAL FOR MENTAL DISORDERS (DSM-IV), GAF scores range from 1 to 100, depending on the level of a person's occupational and social functioning. The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). DSM-IV at 46-47. GAF scores from 61 to 70 reflect 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, with some meaningful interpersonal relationships. Id. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). Id. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). Id. VA treatment records dated April 2006 noted symptoms of sadness, tearfulness, anhedonia and low energy. He also had feelings of worthlessness and hopelessness. He had nightmares every day and occasional flashbacks. He endorsed hypervigilence. On examination, the Veteran was appropriately dressed and groomed. His mood was depressed and his affect was euthymic. Speech and psychomotor activity were normal. Thought processes were logical. Judgment and insight were intact. There was no indication of suicidal or homicidal ideation. Additional records from September 2006 noted that the Veteran's depression had improved, but he continued to experience symptoms. He had frequent nightmares of Korea, and rolled out of bed thinking his was being attacked in his foxhole at night. His nightmares caused difficulty with sleeping. Mental status examination results were identical to those from April 2006. In December 2006, the Veteran reported that he had moved to a separate bedroom from his wife due to violent dreams. In February 2007, the Veteran reported continued difficulty with daily nightmares. At times he felt like he would like to die. He had no clear plan on hurting himself, but stated that he would make sure it looked "natural" to preserve insurance policies for the benefit of his spouse. He also made general inquiries about physician assisted suicide. He continued to experience guilt over traumatic events from service. On examination, he was unshaven but otherwise appropriately dressed and groomed. He was fully oriented and his speech and thought processes were normal. In July 2007 and November 2007, the Veteran reported that he felt short-tempered and had difficulty controlling his words. He still had nightmares, but he slept fairly well. His mood was good, and he had no anxiety. Examination revealed a depressed mood and euthymic affect. Appearance, speech, psychomotor activity, thought processes, judgment, insight, and cognitive function were normal. A VA examination was conducted in August 2007. The report noted that the Veteran treated his condition with medication, and that he had recently started group therapy. The Veteran reported that his condition had worsened over the past year, particularly in the last several months. His nightmares had become more extensive in content. His medication had not reduced his nightmares, but did improve sleep. He had good relationships with his wife and son, enjoyed seeing his grandchildren, and had some acquaintances, but was otherwise a loner and felt somewhat detached from others. He denied any current intent to harm himself, but stated that he did not see much purpose in living anymore. However, seeing his grandchildren grow up has made him question that attitude. He reported digging some holes in his backyard to "hide in" in case someone came looking for him. He denied any history of panic attacks, obsessive behavior, or impaired impulse control. On examination, the Veteran was alert and oriented. Thought processes were linear and goal-oriented. There was no evidence of delusions or hallucinations. Personal hygiene was adequate. He reported some subjective memory complaints, though no significant deficits were noted on examination. His GAF score was 50-55. The examiner stated that the Veteran's PTSD symptoms were stable since his last examination. Overall, there were intermittent periods of inability to perform certain tasks or a decrease in general efficiency, but he had generally satisfactory functioning in regard to routine behavior, self-care, and conversation. Additional VA records dated May 2008 show the Veteran reported feeling hopeless about the future, but he denied any suicidal ideation. In August 2009, the Veteran's GAF score was noted to be 50, and he was not a risk for hurting himself or others. In April 2010, the Veteran returned to treatment following a 2 year absence. He felt depressed and short-tempered. He continued to have nightmares. He felt fatigued, discouraged, and unhappy with life, but denied feeling hopeless about the future. He also denied any suicidal ideation. Examination revealed a depressed mood and euthymic affect. Appearance, speech, psychomotor activity, thought processes, judgment, insight, and cognitive function were normal. Another VA examination was conducted in April 2010. The Veteran reported daily symptoms of mild to moderate severity. He had daily nightmares and stated that his depression was "pretty bad." He was noted to say, "I just can't see why a person like me lives." He denied any legal history, and had a good relationship with his family. He also had 2 or 3 good friends. He enjoyed taking his wife shopping and doing some housework. He also watched television and took naps during the day. He denied any obsessive behavior, panic attacks, or recent history of violence. On examination, he demonstrated no impairment of thought process or communication. There were no delusions or hallucinations. He endorsed some general suicidal ideation, without specific plan or intent. He was fully oriented, and his hygiene was adequate. Speech was normal. The examiner identified a GAF of 60 for PTSD and a GAF of 55 for dysthymia. Notably, the examiner incorrectly identified dysthymic disorder as a nonservice-connected condition. VA treatment records from September 2012 through January 2013 reflect GAF scores of 65. The Veteran underwent an additional VA examination in January 2013. The examiner stated that the Veteran's condition resulted in occupational and social deficiencies in most areas, such as work, school, family relationships, judgment, thinking, and mood. The examiner also noted that the Veteran's wife had passed away in March 2012. He reported frequent thoughts of suicide but "talked himself out of it." Other symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances in motivation and mood, and difficulty adapting to stressful circumstances. He treated his condition with medication and group therapy. His GAF score was 55. Based on the evidence, the Board finds that a rating in excess of 30 percent is not warranted prior to January 10, 2007. The evidence during that period reflects findings of depressive symptoms and sleep impairment. However, those are expressly contemplated by the assigned 30 percent rating. The Veteran's condition during this period is not manifested by symptoms such as abnormal speech, panic attacks, difficulty in understanding complex commands, memory impairment, impaired judgment, or impaired abstract thinking. It is not manifested by other symptoms which result in an overall disability picture consistent with a higher 50 percent rating. From January 10, 2007 to January 31, 2013, a rating in excess of 50 percent is not warranted. Although the Veteran endorsed significant suicidal ideation during this period, his condition was not otherwise manifested by symptoms consistent with a higher rating. He had no obsessive behavior, no speech abnormalities, no panic attacks, no spatial disorientation, and no periods of violence. He was able to maintain proper hygiene and demonstrated effective relationships with his family and others. An August 2009 GAF score of 50 reflects serious symptoms. However, additional scores during this period range from 55 to 65, which reflect moderate symptomatology, and are consistent with the assigned 50 percent rating. The August 2007 examiner also stated that the Veteran had generally satisfactory functioning in regard to routine behavior, self-care, and conversation From January 31, 2013, the date of the most recent VA examination, a higher 70 percent rating is warranted. That examiner specifically noted that the Veteran's condition resulted in occupational and social deficiencies in most areas, such as work, school, family relationships, judgment, thinking, and mood, which, when viewed with the Veteran's ongoing suicidal ideation, is consistent with the rating criteria for a 70 percent evaluation. However, a higher 100 percent rating is not warranted. At no time did the Veteran endorse profound symptoms such as persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for basic concepts such as his own name. His overall level of impairment, as well as his GAF scores throughout the period on appeal, are not consistent with a 100 percent rating, which contemplates total disability. C. Diabetes Mellitus The Veteran is assigned a 20 percent rating for diabetes mellitus type II under Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet; or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2012). VA treatment records dated June 2005 show the Veteran's diabetes was not controlled. He was advised to check sugars before and after exercise, and before breakfast and dinner. Additional records from January 2006 show diabetes to be well-controlled, and records from August 2006 show the Veteran's diabetes was treated with insulin only. Records from June 2007 show the Veteran reported occasional high sugar levels if he eats the wrong foods. He had occasional low sugars if he skipped meals or ate late. He felt weak between 1 pm and 3 pm. He took insulin routinely at 7:30 am or 8 am. He rarely notice low readings at 10 am or 11 am, but frequently had readings in the 70's at 2 pm or 3 pm. The Veteran underwent a VA examination in August 2007. He treated his condition with insulin, and saw his treating physician every 3 or 4 months. He reported rare instances of hypoglycemia with he treated with eating, and denied any ketoacidosis. He did not restrict his activities to maintain a stable blood sugar level. Treatment records dated September 2009 show fasting blood sugar levels ranging from 91 to 177 during a one week period. In April 2010, the Veteran's diabetes was noted to not be well-controlled. He was advised to take regular insulin only with meals. The Veteran underwent a general VA examination in August 2010. He denied any episodes of ketoacidosis or hypoglycemia, or hospitalizations due to diabetes. He tried to follow a healthy diet, but did not restrict his activities to maintain stable blood sugar levels. VA treatment records dated August 2012 noted that the Veteran was experiencing possible hypoglycemic events at home. Another VA examination was conducted in January 2013. The Veteran treated his condition with more than 1 insulin injection per day. He did not regulate his activities as part of his diabetes management. He had experience no hospitalizations for ketoacidosis or hypoglycemia, and visited his care provider less than twice a month for such episodes. He had experienced no weight loss due to diabetes. The examiner noted that the Veteran had mild renal insufficiency that was not thought to be secondary to diabetes. Based on the evidence, a rating higher than 20 percent is not warranted for the Veteran's diabetes mellitus type II. The record reflects that the Veteran's condition is treated with insulin and a restricted diet, which is consistent with the assigned rating. A higher rating requires the regulation of activities as a component of treatment. However, at no point during the period on appeal was the Veteran advised to regulate his activities. Records and examinations from August 2006, August 2007, August 2010, and January 2013 specifically noted that the Veteran did not regulate his activities to treat his diabetes. Similarly, the record does not reflect ketoacidosis or hypoglycemic reactions requiring hospitalization or twice a month visits to a diabetic care provider. Successive rating criteria, such as Diagnostic Code 7913 for diabetes mellitus, is where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Therefore, the assigned 20 percent evaluation for diabetes mellitus type II is continued. D. Headaches The Veteran is assigned a 10 percent rating for his headaches under Diagnostic Code 8045-8100. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 8045 provides for the evaluation of TBI. 38 C.F.R. § 4.124a (effective October 23, 2008). There are 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. The Veteran's current service-connected and nonservice-connected disabilities include conditions listed under Diagnostic Code 8045. However, in this case, headaches are the only documented manifestation associated with the Veteran's TBI. Other conditions or symptoms listed under Diagnostic Code 8045 which are present in the Veteran have specifically been attributed to other etiologies. For example, he is diagnosed with PTSD. Diagnostic Code 8045 specifically states that emotional/behavioral dysfunction should be rated under 38 C.F.R. § 4.130 when there is a diagnosed mental disorder. Similarly, while he is diagnosed with peripheral neuropathy, hearing loss, and tinnitus, those conditions have also been separately rated under the appropriate Diagnostic Codes, and will not be considered under Diagnostic Code 8045. In addition, a February 2010 VA exam specifically stated that memory loss was due to aging and dementia, and not the Veteran's TBI. Because additional evidence attributes memory loss to PTSD, the Board has considered it in evaluating the Veteran's PTSD above, but there is no affirmative evidence showing that memory loss is due to a TBI. In sum, the only symptom of a TBI is headaches. Under Diagnostic Code 8045, headaches alone do not warrant a higher rating. At least two additional subjective symptoms must be present. Under Diagnostic Code 8100, a 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one episode in 2 months over the last several months. A 30 percent evaluation is warranted for migraines manifested by characteristic prostrating attacks occurring on an average of once a month over several months. A 50 percent evaluation is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Treatment records dated February 2009 show the Veteran had a history of chronic bilateral frontal headaches. He was seen for the first time in November 2008 and prescribed medication. He presented with improved symptoms and stated that he felt like a "new person." A VA examination was conducted in February 2010. He reported constant head pain localized over the left side of the head at the front or temple area. Pain was 6/10 to 7/10 in severity, but occasionally flared-up to higher levels and spread to the back of the head. He had mild photophobia or phonophobia with these flare-ups, but no nausea or visual changes. Flare-ups occurred if he missed a dose of medication, is fatigued or sleepy, or traveled in a car for an extended period. The examiner stated that headaches occurred daily, but there was no significant disruption of day-to-day functioning. The Veteran had a relatively stable presentation best described as a migrainous type headache with the presence of some light sensitivity. In an April 2010 statement, the Veteran reported that he did have vomiting and visual disturbances associated with his headaches, and that his medication failed to reduce his pain. VA records also dated April 2010 reflect similar complaints. The Veteran underwent a general VA examination in August 2010. He reported constant headaches which were more severe in the morning. He felt he sometimes vomited due to headache pain. Headaches also caused him to feel fatigued and lacking in energy. VA records dated November 2010 show the Veteran continued to have constant headaches. His medication helped but did not completely cure his condition. He had no associated numbness, tingling or visual disturbances. The Veteran adamantly stated that he was not throwing up. VA treatment records dated from August 2012 through October 2012 show the Veteran denied any complaints of vomiting. Based on the evidence, a rating higher than 10 percent is not warranted for the Veteran's headaches. As noted above, a higher 30 percent rating under Diagnostic Code 8100 manifested by characteristic prostrating attacks occurring on an average of once a month over several months. The record in this case does not reflect any prostrating attacks during the period on appeal. The Veteran reported associated vomiting and visual disturbances in April 2010. In adjudicating a claim the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences; for example, he is competent to report that he experiences certain symptoms such as right foot pain and limited mobility. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds the Veteran to be credible in his reports of the symptoms he experiences. However, he denied those same symptoms in February 2010 and November 2010, and they were not documented during the remainder of the appeal period. The Veteran's account of his symptomatology, when viewed with the medical evidence, describes a level of impairment consistent with the assigned ratings. E. Extraschedular Consideration In evaluating the Veteran's claims for higher ratings, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected conditions in considering if the Veteran is entitled to an extraschedular rating. According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD, diabetes, and TBI with the established criteria found in the rating schedule for those disabilities shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. The criteria for each condition includes symptoms or factors that are associated with higher schedular ratings which are specifically noted to not be present in the Veteran. For example, the Veteran's PTSD does not result in memory loss for basic concepts, such as his own name. Diabetes does not result in hospitalizations for ketoacidosis or hypoglycemia. Headaches are not characterized by rest periods or prostrating attacks. None of the service-connected disabilities on appeal result in any symptoms that fall so far outside the rating schedule as to render it inadequate. ORDER A rating higher than 30 percent for PTSD with dysthymia is denied prior to January 10, 2007. A rating higher than 50 percent for PTSD with dysthymia is denied from January 10, 2007 to January 30, 2013. A 70 percent rating for PTSD with dysthymia is granted from January 31, 2013, subject to the laws and regulations governing the award of monetary benefits. A rating higher than 20 percent for diabetes mellitus type II is denied. A rating higher than 10 percent for headaches due to a concussion is denied. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs