Citation Nr: 1326733 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 09-31 489 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for residuals of head trauma, to include memory loss. 2. Entitlement to service connection for a heart disorder, to include vertigo and diplopia. 3. Entitlement to an initial disability rating in excess of 10 percent for major depressive disorder. 4. Entitlement to a disability rating in excess of 10 percent for gastritis. 5. Entitlement to an increased disability rating for headaches, rated as noncompensable prior to November 30, 2011, and rated as 30 percent disabling from November 30, 2011, to the present. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: John R. Worman, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from January 1983 to June 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testisfied before the undersigned Veterans Law Judge during a hearing held at the RO in March 2011. A transcript of the hearing has been included in the claims file. The case was most recently before the Board in September 2011, at which time the Board remanded the claims to the RO via the Appeals Management Center (AMC) for additional development and adjudicative action. The case has now been returned to the Board for further appellate review. In the September 2011 remand, the Board also remanded a claim for entitlement to service connection for sinusitis. In a September 2012 rating decision, the AMC granted service connection for allergic rhinitis (previously claimed as sinusitis), and assigned an initial noncompensable rating for the disability. The Veteran has not disagreed with the assigned evaluation or effective date for the disability, and he has not perfected an appeal in either regard. Therefore, that matter of service connection for rhinitis (previously claimed as sinusitis) has been resolved, and the claim is not in appellate status. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). In a December 2012 rating decision, the RO increased the disability rating for the Veteran's service-connected headaches from noncompensable to 30 percent disabling, effective from November 30, 2011. On a claim for an increased rating, a Veteran will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Since the rating assigned in the December 2012 rating decision does not constitute a full grant of the benefit sought throughout the entire appeal period, and since the Veteran did not withdraw his claim of entitlement to a higher rating, the issue remains before the Board for appellate review. In April 2013, the Veteran's representative submitted additional evidence in support of his TDIU claim and a waiver of the RO's consideration of this evidence in the first instance. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. The issues of service connection of residuals of head trauma and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence does not show that the Veteran's current mitral valve regurgitation disorder is related to his military service or any incident therein. 2. Since the grant of service connection, the Veteran's depressive disorder has been productive of no more than social and occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. Throughout the appeal, the Veteran's headaches disability has more closely approximated characteristic prostrating attacks occurring on an average once a month over the last several months. 4. Throughout the appeal, the Veteran's gastrointestinal symptomatology has not approximated small eroded or ulcerated areas, persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, or other symptom combinations productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart disorder are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The criteria for an initial 30 percent disability rating, but no greater, for depressive disorder are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.130, Diagnostic Code 9434 (2012). 3. Throughout the entire pendency of the appeal, the criteria for a 30 percent disability rating, but no higher, for headaches are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8100 (2012). 4. The criteria for a disability rating in excess of 10 percent for gastritis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.113, 4.114, Diagnostic Codes 7307, 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's claim of entitlement to an increased rating for his depressive disorder arises from his disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed. As for the heart disorder, headaches, and gastritis claims, the record reflects that the Veteran was provided all required notice in letters mailed in February 2008 and October 2008. These letters provided the Veteran with notice of what type of information and evidence was needed to substantiate his claim, as well as notice of the type of evidence necessary to establish a disability rating and an effective date. He was also provided notice regarding the rating criteria for the diagnostic codes relevant to his increased rating claims. Although the October 2008 notice letter was provided after the initial adjudication of his claims, the Veteran's claims were readjudicated, with the most recent adjudication occurring in the February 2013 SSOC. Nothing more is required. VA also has a duty to assist a Veteran in the development of his claims. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained available service treatment records and identified VA and private treatment records. As directed by the September 2011 remand, outstanding VA records dated up until 2013 have been included in the record. The Veteran also submitted written statements discussing his contentions and provided testimony at his hearing before the Board. Most recently, the claims were remanded so that the Veteran could be afforded VA examinations. The Board finds the VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claims. As for the heart disorder claim, the November 2011 VA examiner considered all of the pertinent evidence of record, to include service and post-military treatment records, and the statements of the Veteran, and provided a complete rationale for the opinions stated. Regarding the depressive disorder, headaches, and gastritis claims, the May 2008, November 2011, and January 2013 VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his service-connected disabilities under the applicable rating criteria. Additionally, there is also no objective evidence indicating that there has been a material change in the severity of the Veteran's claimed disabilities since they were last assessed in November 2011 and January 2013. As the Veteran has been provided with adequate examinations with respect to his claims and his outstanding medical records have been obtained, the RO has substantially complied with the September 2011 remand directives. See D'Aires v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Accordingly, the Board will address the merits of the claims. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Service Connection for a Heart Disorder Here, the Veteran claims that he currently has a heart disorder due to his military service. He asserts that he was assessed as having a heart murmur while on active duty, which he claims is related to his current heart disorder. The Veteran also attributes his current mitral valvular heart disorder to a fall he sustained in May 1987 during service. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004)(citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)(table). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a Veteran had a chronic condition in service or during the applicable presumptive period. In addition, chronic diseases, including endocarditis (this terms covers all forms of valvular heart disease), may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. § 3.307, 3.309. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim; the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Turning to the merits of the claim, the Veteran's service treatment records have been reviewed and are negative for a heart murmur or mitral valvular heart disease diagnosis. These records do show, however, that the Veteran was assessed with mild sinus bradycardia during a December 1989 medical examination. He was diagnosed with hypercholesterolemia in February 1992 following a flight physical examination. The Veteran's June 1993 separation report of medical examination shows that the clinical examination of the heart and vascular system was generally normal. He denied ever having any heart trouble on the associated June 1993 separation report of medical history. Additional service treatment records show that the Veteran sustained injuries in May 1987 when he sustained a fall off of a ledge. He was subsequently treated for orthopedic conditions. The records associated with his injuries are negative for reports or diagnoses related to a cardiac disorder. Post-military VA treatment records show a diagnosis of mitral regurgitation in January 1999. An April 1999 VA record shows a diagnosis of mitral valve prolapse with mitral regurgitation. Subsequent VA and private treatment records show treatment for mitral valve disease, to include mitral valve repair in April 2004. An October 2006 VA treatment record includes the Veteran's report of experiencing dizzy spells and dilopia ever since his heart surgery. As reflected in a January 2007 private medical note, the Veteran was later assessed as having cardiac presyncope/syncope. At the time of this diagnosis, the Veteran's private physician essentially opined that the Veteran's symptoms were secondary to a primary cardiac etiology. In support of his claim, the Veteran submitted statements from his friends B.J.S. and D.S. who both relayed that the Veteran experienced dizzy spells. In his September 2007 statement, D.S. reported that the Veteran experienced these episode since June 2004. In her August 2007 statement, B.J.S. stated that the Veteran's dizzy spells appeared to have gotten worse during the previous two to two and a half years. A February 2008 VA treatment record shows that the Veteran's treating physician requested an opinion from a VA cardiologist regarding whether mitral valve disease could be caused by stress and whether the disorder could be considered to have occurred in the line of duty. His physician relayed the Veteran's belief that since stress can cause or worsen hypertension and hypertension can cause or worsen mitral valve disease, his mitral valve disease may be attributable in part to the stress of his work environment. In a March 2008 response, the VA cardiologist noted that the Veteran was assessed with myxomatous mitral valve degeneration with resultant leaflets prolapse. The cardiologist stated that in the Veteran's case, his mitral regurgitation appeared to be a result of progressive structural valvular disease and not caused by work-related stress or hypertension. The Veteran underwent a VA examination in November 2011, at which time he expressed his contention that his 1987 in-service fall may have damaged his heart. He stated that his dizzy spells started after the fall and that he began to have problems with passing out following his 2004 surgery. He also expressed his belief that his heart problems may be stress related. The clinical examination revealed diagnoses of cardiac arrhythmia and mitral valve regurgitation. After reviewing the claims file, the examiner opined that the Veteran's mitral valve regurgitation and high grade atrioventricular (AV) block status post pacer placement were not due to his military service, to include his in-service sinus bradycardia and hypercholesterolemia diagnoses. The examiner highlighted that the Veteran's service treatment records were silent for a heart murmur or any other sign of a mitral valve condition. The examiner noted that the medical records did not show objective evidence of any heart valve condition until 1997 when a nonspecific murmur was noted. This occurred beyond the time period to presume that it was due to service. The examiner highlighted that there was no objective evidence of mitral valve disease until 1999, over five years after service. The November 2011 examiner also explained that hypercholesterolemia is a laboratory value that causes no functional limitation. Although the examiner noted that hypercholesterolemia was one of the risk factors for atherosclerotic heart disease, the examiner stated that there was no objective evidence that the Veteran has this type of heart disease. Additionally, the November 2011 examiner determined that the Veteran's in-service bradycardia was physiologic. The examiner explained that well conditioned athletes and military personnel often have very efficient hearts and do not need high heart rates to circulate blood adequately. As indicated by the service treatment records, the Veteran's bradycardia was noted but not treated during service and was not considered to be pathologic. The examiner determined that this was considered normal for healthy, "in shape" individuals. According to the examiner, the medical literature provided no support that physiologic bradycardia in healthy youth leads to AV block later in life. The examiner further highlighted that a review of the Veteran's VA records showed no heart rate below 60 from April 1999 until the AV block was noted in 2010. The examiner stated that the in-service electrocardiograms were normal, other than his low heart rate. Given these factors, the examiner concluded that there was no objective evidence of the onset of a heart disorder during service. Having reviewed the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection for a heart disorder, to include reported symptoms of vertigo and diplopia. Although the medical evidence of record dated during the course of the appeal reflects current diagnoses of mitral valve regurgitation and arrhythmia, the preponderance of the evidence does not indicate that these conditions were caused by or is otherwise related to the Veteran's military service. Accordingly, the claim for service connection is denied. The Veteran primarily contends that that his current heart disorder had its onset in service and that the condition is related to his May 1987 in-service fall. Although his service treatment records show that he suffered a fall in 1987, the Board again highlights that the records associated with the treatment of the injuries sustained due to this incident are entirely negative for a diagnosed cardiac disorder. The Board also acknowledges the sinus bradycardia and hypercholesterolemia diagnoses reflected in the service treatment records. However, the objective evidence does not show that his in-service diagnoses caused or are related to his current mitral valve disorder. The only medical evidence of record assessing the relationship between the Veteran's military service and his mitral valve regurgitation is the November 2011 VA examiner's opinion. Based on a review of the claims file, and relevant medical literature, along with consideration of the results of the clinical examination and the Veteran's competent lay statements, the examiner provided an opinion against the claim for service connection for a heart disorder. The Board finds the VA medical opinion to be highly probative and compelling evidence against the Veteran's claim that his claimed heart disorder had its onset or is related to his military service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 299-301 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no competent medical evidence of record to rebut the opinion against the claim or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). Regarding the Veteran's in-service diagnosis of sinus bradycardia, and his current diagnosis of cardiac arrhythmia, the Board again finds the November 2011 examiner's opinion to be the most probative evidence of record. See Nieves-Rodriguez, 22 Vet. App. at 299-301; Stefl, 21 Vet. App. at 124. The November 2011 examiner determined that the Veteran's in-service bradycardia was not considered to be pathologic and that this was essentially normal for well conditioned military personnel. Although he currently experiences a variable heart rate (arrhythmia), the November 2011 considered this finding and determined that there was no objective evidence of an in-service heart disorder during service. Thus, service connection is not warranted based on any current cardiac diagnosis. The Board further notes that evidence does not show a diagnosis of mitral valve regurgitation until many years following the Veteran's separation from active duty. The evidence shows that mitral valve regurgitation was first diagnosed in 1999, approximately eight years after the Veteran's discharge from service. The Board notes that evidence of a prolonged period without medical complaint and the amount of time that elapsed since active duty service can be considered as evidence against a claim. Maxson v. Gober, 230 F.3d 1330, 1333 (2000). Essentially, the evidence does not show that the Veteran's mitral valve regurgitation was diagnosed within a year of his discharge from the military in June 1993, and therefore, presumptive service connection is not warranted in this case. See 38 C.F.R. §§ 3.307, 3.309. The Board has also considered the Veteran's statements regarding of a continuity of cardiac symptomatology since his military service. Although the Veteran is competent to describe his cardiac symptomatology and his military experiences, the Board does not find his statements as to the onset and continuity of the claimed in-service cardiac disorder to be credible. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Here, the Board highlights that the Veteran's service treatment records are entirely negative for reported cardiac symptomatology. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (finding that contemporaneous evidence has greater probative value than history as reported by the claimant). Indeed, the Veteran denied having any heart trouble on his June 1993 separation report of medical history. This stands in contradiction to his current reports that his mitral valve disorder had its onset during his military service. See Macarubbo v. Gober, 10 Vet. App. 388 (Fed. 1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, and inconsistency with other evidence of record). The Board also notes that the Veteran made no reports of continuing cardiac symptoms until many years after his separation from the military. Given this, the evidence of record does not support the award of service connection based on a continuity of symptomatology. In reaching the above decision, the Board again highlights that consideration has been given to the Veteran's lay statements regarding his belief that he currently has a heart disorder that is related to his military service. While his statements are competent evidence of what the Veteran experienced and his current symptomatology, these statements are not competent evidence to establish that his heart disorder is related to his military service. Whether the Veteran's current heart disorder is related to or was caused by service does not lie within the range of common experience or common knowledge, but requires special experience or special knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). It is not shown that the Veteran possesses the ability, knowledge, or experience to provide a competent etiological opinion regarding the relationship between his military service and his current heart disorder. See Jandreau, 492 F.3d 1372; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the lay statements from the Veteran as to medical causation are not competent evidence to establish service connection. Id. Accordingly, the claim for service connection for the Veteran's claimed heart disorder must be denied for the foregoing reasons. In arriving at this decision, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim of entitlement to service connection in this case, the doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As such, entitlement to service connection for a heart disorder is not warranted. Legal Criteria for Increased Ratings Disability evaluations are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. Separate Diagnostic Codes identify various disabilities and the criteria for specific ratings for the disabilities. The percentage ratings represent as far as practicably can be determined the average impairment in earning capacity due to a service-connected disability. 38 U.S.C.A. § 1155. The evaluation assigned is determined by comparing the extent to which a Veteran's service-connected disability impairs his ability to function under the ordinary conditions of daily life, as demonstrated by the Veteran's symptomatology, with the schedule of ratings. Id.; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established (as is the case for the low back disability) and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v Brown, 7 Vet. App. 55 (1994). However, with regard to the depressive disorder claim, the Board notes that the Veteran is appealing the initial assignment of disability rating, and as such, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. VA must resolve any reasonable doubt regarding the degree of disability in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Where there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7, see also 38 C.F.R. § 4.21. Major Depressive Disorder The claims file reflects that, in the July 2008 rating decision, the RO granted service connection for depressive disorder as secondary to the Veteran's service-connected low back disability. An initial 10 percent rating was assigned effective from February 11, 2008. Thereafter, the Veteran perfected an appeal as to the initial rating assigned for his psychiatric disability. The Veteran's service-connected depressive disorder is evaluated under Diagnostic Code 9434. The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Under this diagnostic code, a 10 percent evaluation is warranted when the Veteran exhibits occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; when symptoms are controlled by continuous medication. A 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is contemplated for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is contemplated 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent disability rating is contemplated 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. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The 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. Id. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the AMERICAN PSYCHIATRIC ASSOCIATION'S DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV), at 32). GAF scores ranging between 61 and 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, and has some meaningful interpersonal relationships. DSM-IV at 46-47 (4th ed. 1994). Turning to the merits of the claim, an October 2002 VA psychology treatment record shows that the Veteran presented with an angry mood and a loud, angry voice. The examiner described the Veteran's mentation as rigid with a passive/dependent passive/aggressive interpersonal style. The examination revealed a diagnosis of a mood disorder due to back and leg pain. The claims file includes portions of a private neuropsychological evaluation of the Veteran which appears to have been completed in March 2005. The Veteran described his mood as variable. He reportedly experienced increased irritability and anger with driving, and he sometimes had angry outbursts towards other drivers. He stated that he woke up in the middle of the night due to pain or his need to use the bathroom. The Veteran also stated that his interest in usual activities was diminished, and his activity level was down. His outlook toward the future was uncertain, and he reported feeling guilt all of the time. The Veteran previously had suicidal thoughts, but he denied any recent suicidal ideations. He reported having severely impaired memory and moderate difficulty with concentration and attention. The Veteran was able to groom and bathe himself and also perform household chores. On the clinical examination, he was described as well dressed and well groomed. His affect appeared irritated with certain questions due to his perceived problem with recalling past details. The examiner stated that the Veteran was often non-committal with his responses, but that he appeared to provide good effort during the examination. His mood appeared more friendly and cooperative during the course of the evaluation. The examination revealed relatively intact cognitive functions, with some mild inefficiency noted in the area of verbal memory functioning. Based on the examination results, the examiner determined that the Veteran experienced a minimal level of depressive symptoms, with some findings suggesting that he had a strong tendency to somaticize and over-report his symptoms. The evaluation revealed a mild degree of psychological distress. The examiner rendered a diagnosis of depressive disorder. The Veteran underwent a VA examination in May 2008 to assess the severity of his service-connected depressive disorder. He estimated that he felt depressed approximately six to seven times during the previous two weeks. He attributed his current depression primarily to the recent death of his brother, losing his job one year prior, and essentially his feelings of not receiving help at the VA. The Veteran reportedly slept three to nine hours within a twenty-four hour period, and he stated that his energy level was affected by pain. He also reported having problems with concentration; the examiner noted that a April 2002 neuropsychological examination revealed cognitive functioning within normal limits. The Veteran denied any current suicidal ideations, and he did not demonstrate any signs or symptoms of mania. The Veteran stated that he was twice divorced, but he dated casually. He had two to three friends and enjoyed working on the computer and around his house. There was no reported history of suicide attempts, violence, or assaultiveness. The examiner noted that the Veteran was prescribed anti-depressive medications. On the psychiatric examination, the Veteran was described as neatly groomed and appropriately dressed. His speech was unremarkable, spontaneous, and clear. His attitude was friendly and attentive, and his affect was normal. The Veteran described his mood as "fair." His attention and his orientation were intact, with the exception of the Veteran missing the correct date by one day. Thought process and thought content were unremarkable. The examination was negative for evidence of delusions, hallucinations, or inappropriate behaviors. The Veteran understood the outcome of his behavior and partially understood that he has a problem. He was noted to have passive suicidal thoughts in the past, but no current suicidal or homicidal ideations. His impulse control was fair. The Veteran's memory was normal. The examiner noted that the Veteran had been unemployed for one to two years from his usual occupation as a corrections officer. The Veteran attributed his employment to his dizzy spells and back problems; he denied that his unemployment was due to his psychiatric disability. The examination revealed a continued diagnosis of depressive disorder and GAF score of 70. The examiner determined that the Veteran's mental disorders symptoms were not severe enough to interfere with his occupational and social functioning. The Veteran provided testimony regarding his psychiatric symptoms during the March 2011 hearing. He essentially stated that he did not have any friends and that he did not engage in any outside social activities. With the exception of his sister-in-law, all of his family members were deceased. He reported having mood swings of varying durations. The Veteran indicated that he had a prior history of domestic abuse and difficulty at work. During a November 2011 VA examination, the Veteran reported having a depressed mood, anxiety, and chronic sleep impairments. He reportedly slept two to nine hours a night, but reported that most of the time he woke up due to nightmares. He described his anxiety and depressed mood as chronic and mild. He stated that he was suspicious about things and was "jumpy" with noises. The Veteran indicated that he was in a down mood "a lot of times." The examiner noted that the Veteran's depression, difficulty sleeping, and difficulty concentrating could be due to his depressive disorder and/or a nonservice-connected condition. The Veteran reported that he was twice divorced, was dating, and that he had two friends. He indicated that he would enjoy scuba diving and boating if he was in better health. There were no reported symptoms suggestive of mania, hypomania, or psychosis. When asked whether he experienced panic attacks, the Veteran responded that he got startled and scared very easily. The clinical examination revealed that the Veteran was alert and fully oriented. He recalled 3/3 items immediately, and 2/3 items after a delay of a few minutes with prompts. There were no remote memory impairments. The examination revealed a continued diagnosis of depressive disorder, which was characterized as relatively mild. The examiner determined that the Veteran's symptoms were not severe enough to either interfere with his occupational and social functioning or to require continuous medication. The examiner noted, however, that the Veteran's primary care physician prescribed him anti-depressive medications. He determined that the Veteran's depressive disorder was not severe enough to prevent the Veteran from either obtaining or maintaining employment. According to the examiner, the Veteran's psychiatric disability did not to interfere with his social functioning. Based on a review of the evidence, the Board finds that the Veteran's depressive disorder has manifested with symptoms that have more closely approximated the criteria for a 30 percent rating since the grant of service connection. The clinical findings contained in the VA and private treatment records and examination reports, and the Veteran's competent and credible lay statements, reflect that his depressive disorder has primarily been manifested by symptoms of depression, sleep disturbance, nightmares, anxiety, diminished interest in activities, irritability, limited social relationships, episodes of angry verbal outbursts, a history of passive suicidal thoughts, and feelings of suspiciousness. The May 2008 VA examination revealed a GAF scores of 70, which is indicative of mild impairments in social and occupational functioning. In light of this, and resolving all doubt in the Veteran's favor, his depressive disorder symptoms are accounted for in a disability rating of 30 percent, and are shown to have been present since the grant of service connection. The evidence, however, does not otherwise show that the Veteran's depressive disorder has resulted in more severe symptoms at any time during the course of this appeal, such as those set forth in the criteria for the next higher rating of 50 percent. For instance, his speech and insight have been intact. Symptoms such as flattened affect, panic attacks occurring more than once a week, and difficulty in understanding complex commands have not been shown. Although the Veteran reportedly has limited social relationships and had difficulty with coworkers when he was employed, he has reported having at least two friends and romantic relationships. There is no indication that the Veteran has difficulty in either establishing or maintaining effective social and work relationships. Indeed, the March 2005 private examiner, May 2008 VA examiner, and November 2011 VA examiner all characterized the Veteran's psychiatric symptomatology as no more than mild based on the results of the clinical examinations. Essentially, the currently assigned 30 percent rating adequately reflects the mild degree of social and occupational impairment caused by his service-connected disability. Here, the Board acknowledges that the evidence does show some disturbance in mood and motivation. Again, the Board notes the Veteran's reports of a variable mood, depression, and decreased interest in usual activities. Nonetheless, the Board finds that his symptoms overall, still more nearly approximate the criteria of a 30 percent rating. There is no competent evidence to show that he meets the next higher rating criteria which would require a showing of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Thus, a disability rating higher than the 30 percent evaluation assigned herein is not warranted. In summary, the Veteran's service-connected depressive disorder warrants no more than a 30 percent disability since the effective date of service connection. See Fenderson, 12 Vet. App. 119. The Board has considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claim for an even higher rating, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Headaches The Veteran claims that his service-connected headaches are more severe than what is reflected by the currently assigned disability ratings. The claims file reflects that service connection was awarded for headaches in a May 2004 rating decision, and the RO assigned an initial noncompensable disability rating. In June 2007, the Veteran filed the claim for an increased rating presently on appeal. Thereafter, in a December 2012 rating decision, the RO awarded a 30 percent rating for the headaches disability effective from November 30, 2011. Throughout the pendency of the appeal, the Veteran's headaches disability has been rated under Diagnostic Code 8199-8100. 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. Diagnostic Code 8199 represents an unlisted disability requiring rating by analogy to one of the disorders listed under 38 C.F.R. § 4.124a. See 38 C.F.R. § 4.27. Diagnostic Code 8100 is the only Code section to address headaches. Under Diagnostic Code 8100, a 10 percent disability rating is warranted for characteristic prostrating attacks, averaging one in 2 months over the last several months. A 30 percent disability rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is assigned for migraine with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. VA regulations, including the rating criteria, do not define "prostrating" as used in Diagnostic Code 8100. The Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, Third College Edition (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th ed. 1994) in which "prostration" is defined as "extreme exhaustion or powerlessness." During the March 2011 hearing, the Veteran testisfied as to his headache symptomatology. He reported having headaches approximately one to three times per week of varying durations. Veteran stated that he was currently taking medication for his headaches, but that the best treatment for his symptoms was lying down and trying to sleep in a completely darkened room. In regards to the frequency and severity of his headaches, a May 2008 VA neurology examination report includes the Veteran's report of experiencing headaches two to three times per week. He described the severity of his headaches as a 10 on a scale from 1 to 10, with ten being the most severe. The Veteran described his headaches as sometimes prostrating. The Veteran stated that his symptoms were aggravated by increasing light. Although he previously tried pain medications, he reported that the medications did not relieve his pain and that he was not recieiving treatment for his disaibity. Rest was reported as the best therapy for his headaches. A November 2011 VA examination report shows that the Veteran reported having three to four heads a month ever since his military service. The Veteran characterized his headache pain as squeezing and localized to one side of his head. His headaches were associated with nausea and sensitivity to sound and light, and were of a duration spanning from one to three hours. He treated his headaches with the use of prescription medications as needed. The Veteran also indicated that he experienced prostrating attacks of headache pain more than once a month. However, he did not have very frequent prostrating and prolonged attacks of his headache pain. The examiner determined that the Veteran's headaches impacted his ability to work in that Veteran reportedly was unable to function during headaches and would either have to miss or leave work. In light of the evidence of record, and resolving all doubt in the Veteran's favor, the Board finds that entitlement to a 30 percent disability rating for headaches is warranted for the entire time period on appeal. As reflected above, throughout the appeal period, the Veteran has experienced headaches of a varying frequency, occurring as infrequently as four per month and as frequently as three times a week. He experiences prostrating attacks of headache pain monthly, and his headaches are associated with nausea, and a sensitivity to light and sound. He treats his symptoms with the use of pain medication, although he identified rest as the best therapy for his disability. In light of the Veteran's competent and credible lay statements regarding the frequency and severity of his headaches throughout the pendency of the appeal, the Board finds that his headaches disability more closely approximates symptoms characterized by prostrating attacks occurring on an average of once a month over the last several months. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting that lay evidence is competent with regard to facts perceived through the use of the five senses). As such, the Board finds that the Veteran satisfies the 30 percent disability rating criteria for his headaches disability for the entire period on appeal. However, the evidence does not indicate that the highest 50 percent disability rating is warranted for the Veteran's headaches at any time during the pendency of the appeal. There is no indication that his headaches are frequently prolonged, completely prostrating, and productive of severe economic inadaptability. Indeed, the Veteran denied having frequent prostrating and prolonged headache attacks during the most recent November 2011 VA examination. While he reported that he was unable to function during headaches and that he had to miss or leave work when he was employed, there is no objective evidence of record that the Veteran's disability is productive of severe economic inadaptability. The Board notes that some interference with employment is contemplated by a 30 percent disability rating. As such, the evidence shows that the Veteran's headaches disability picture more closely approximates an evaluation of 30 percent rather than a 50 percent. In summary, a 30 percent rating, but no higher, is warranted for the Veteran's headaches disability throughout the entire pendency of the appeal. As there appears to be no identifiable period on appeal during which this disability manifested symptoms meriting a disability rating in excess of the 30 percent disability rating assigned and upheld herein, staged ratings are not warranted. See Hart, 21 Vet. App. 505 (2007). Gastritis The Veteran asserts that his service-connected gastritis disability is more severe than what is reflected by the currently assigned 10 percent disability rating. Service connection for this disability was granted by way of a March 1995 rating decision, with a noncompensable rating assigned from June 1993. The RO assigned a 10 percent rating for the disability in an October 1998 rating decision. In February 2008, the Veteran filed the claim for an increased rating presently on appeal. The Veteran's gastritis disability is currently evaluated under Diagnostic Code 7307, which provides the ratings for hypertrophic gastritis. Chronic hypertrophic gastritis, with small nodular lesions, and symptoms is rated 10 percent disabling. Chronic hypertrophic gastritis, with multiple small eroded or ulcerated areas, and symptoms, is rated 30 percent disabling. Chronic hypertrophic gastritis, with severe hemorrhages, or large ulcerated or eroded areas, is rated 60 percent disabling. Atrophic gastritis, which is a complication of a number of diseases, including pernicious anemia, is to be rated on the underlying condition. 38 C.F.R. § 4.114. The Board notes that the medical evidence reflects that a diagnosis of gastroesophageal reflux disorder (GERD) and contains conflicting medical opinions regarding whether the Veteran's service-connected disability is manifested by GERD. The Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Accordingly, unless otherwise noted, the Board will treat all reported gastrointestinal symptomatology as if it is attributable to the Veteran's service-connected gastritis disability. In light of the medical evidence indicating that the Veteran's disability is possibly manifested by GERD, Diagnostic Code 7346 is also applicable in this case. (As an aside, the Board notes that the Veteran's gastrointestinal disability was previously evaluated under Diagnostic Code 7346-7307, as reflected in the October 1998 rating decisions). Under this diagnostic code, hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity is rated 10 percent disabling. Hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, is rated 30 percent disabling. Hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health, is rated 60 percent disabling. 38 C.F.R. § 4.114. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. A May 2008 VA examination report reflects the Veteran's report of severe GERD. He reported using medication to treat his condition, and he denied any hematemesis or melena. The Veteran's condition did not affect his activities of daily living. The physical examination revealed a nontender abdomen that was not distended. Bowel sounds were normal and there was no evidence of a hernia. The examiner provided a diagnosis of gastritis. The Veteran testified during the March 2011 hearing that he used medications to treat his stomach problems, which were described as heart burn on a regular basis, avoidance of certain foods, and daily diarrhea. During a November 2011 VA examination, the Veteran reported experiencing acid reflux since his active duty service. The examiner noted that the Veteran's in-service diagnosis of gastritis and his post-service diagnosis of GERD. The Veteran stated that he experienced recurring, non-severe episodes of his gastrointestinal symptomatology four or more times per year. His symptoms included abdominal pain occurring less than monthly, four or more episodes a year of recurrent nausea, and mild vomiting occurring three times per year. He denied having any incapacitating episodes due to his stomach condition. The Veteran used continuous medication to treat his condition. The examiner determined that the Veteran did not presently have gastritis. In a November 2012, the AMC obtained an additional medical opinion regarding the nature of the Veteran' service-connected gastrointestinal disability. The physician detailed a review of the claims file, to include the November 2011 VA examination, in the associated report. Based on this review, the physician essentially opined that the Veteran's gastritis condition, more accurately characterized as GERD, was at least as likely as not incurred in or caused by his military service. The physician commented that the Veteran's service treatment records showed the evaluation and treatment of symptoms consistent with gastritis, rule out peptic ulcer disease. According to the examiner, the Veteran continued to have symptoms after service, was treated for his symptoms, and was given a revised diagnosis of GERD. The Veteran underwent a VA examination in January 2013 to assess the severity of his gastritis disability. The examiner indicated that the claims file was reviewed. The Veteran reportedly required continuous medication to treat his disability, but he did not report experiencing any signs or symptoms related to his condition. There was no esophageal stricture, spasm of the esophagus, or diverticulum noted. The examiner determined that the Veteran did not have any other pertinent physical findings, complications, or signs/symptoms related to his gastrointestinal disability. Following the assessment, the examiner provided a diagnosis of GERD, noted to have been first diagnosed in 1997. The examiner determined that there was no objective evidence of gastritis at this time and determined that the Veteran's GERD was not caused by gastritis or diagnosed during his active duty service. The examiner explained that gastritis is a temporary or chronic irritation of the stomach lining. According to the review of the claims file, the Veteran was diagnosed with gastritis in 1992 after eating spicy foods and consuming alcohol. The gastritis diagnosis was provided based on his symptoms at that time, without the benefit of an endoscopic examination. Given that no other diagnosis of gastritis was recorded, the examiner concluded that the Veteran's in-service gastritis was transient. The examiner further stated that she was unable to find "chronic hypertrophic gastritis" in the claims file. Based on this evidence, the Board does not find that an increased rating for the time period on appeal is warranted. The Veteran's gastrointestinal symptoms have been primarily described as heart burn, infrequent abdominal pain, four or more episodes a year of recurrent nausea, and three episodes of mild vomiting per year. His symptoms are controlled by the continuous use of medication. The evidence of record does not show objective evidence of chronic gastritis with multiple small eroded or ulcerative areas and symptoms or hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, or regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Thus, the preponderance of the evidence is against entitlement to a rating in excess of 10 percent is warranted under either Diagnostic Code 7307 or 7346. In reaching the above determination, the Board has considered whether a higher rating may be assigned under any other diagnostic code relevant to disabilities of the digestive system. However, the evidence of record does not indicate that consideration or any other diagnostic code is warranted or that such would result in a disability rating higher than the currently assigned 10 percent evaluation. See Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348. The Board has also considered the determination in Hart, 21 Vet. App. 505 and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during this appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to increased compensation at any time within the appeal period. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the disability in issue, such that increased evaluations are warranted. For the foregoing reasons, the preponderance of the evidence is against the claim for a disability rating higher than 10 percent for service-connected gastritis. In reaching this decision, the Board has considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Conclusion- Increased Rating Claims In addition to the above considerations, the Board has also considered whether the Veteran is entitled to a referral for an extraschedular rating for the claimed service-connected disabilities. The Court clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made by the RO or Board. If the rating criteria are inadequate, the RO or Board then must proceed to determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, there has been no showing that the Veteran's disability picture could not be contemplated adequately by the applicable schedular rating criteria discussed above for his depressive disorder, headaches, and gastritis disabilities. The Veteran's disabilities were applied to the applicable rating criteria and case law. Although the applicable criteria provide for higher ratings, the Board fully explained why ratings higher than what has been assigned and upheld herein were not warranted. Given that the applicable schedular rating criteria are more than adequate in this case, referral for consideration of the assignment of a disability rating on an extraschedular basis is not warranted for the depressive disorder, headaches, and gastritis disabilities. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for a heart disorder is denied. An initial 30 percent disability rating, but no higher, is warranted for depressive disorder, subject to the laws and regulations governing monetary awards. A 30 percent disability rating, but no higher, is warranted for headaches, subject to the laws and regulations governing monetary awards. A disability rating in excess of 10 percent for gastritis is denied. REMAND Unfortunately, a remand is required with respect to the Veteran's remaining claims. The Veteran asserts that he currently experiences memory loss as a residual condition caused by a fall he sustained in May 1987 during his military service. Although the Veteran has been afforded a VA examination and VA medical opinions have been obtained with respect to his claim, the Board finds that the medical evidence currently of record is inadequate with which to render a decision in this case. Specifically, the Board finds that the most recent November 2011 VA examination report is inadequate due inconsistencies regarding the exact nature of the Veteran's claimed memory loss disorder. In the report, the November 2011 examiner noted the Veteran's in-service and post-service reports of experiencing memory problems following his in-service fall. On the clinical examination, however, the examiner indicated that there were no complaints of memory impairment and no subjective symptoms. Additionally, based on the clinical findings, the examiner provided a diagnosis of traumatic brain injury (TBI), noted to have been diagnosed in May 1987. However, the examiner later concluded that there was no evidence to suggest a definite TBI in service, specifically from the documented 1987 fall. The examiner commented that even assuming that the Veteran had a TBI, there were no residuals from the incident, given that his delayed complaints of memory loss had nothing to do with the TBI and his post-service neuropsychological testing in 2002 was unremarkable. In light of these conflicting findings, it is unclear whether the November 2011 examination and opinion reflect an accurate assessment of the claimed disorder. In November 2012, the AMC obtained an addendum opinion from a VA physician in an effort to clarify whether the Veteran had a diagnosed TBI, and if so, whether it was related to his in-service fall. The physician reviewed the claims file and provided the requested opinion without the benefit of a new examination. Based on a review of the claims file, the examiner opined that a TBI was at least as likely as not incurred in or caused by claimed in-service injury. The physician explained that while a loss of consciousness and concussion not specifically diagnosed in service, it would be unreasonable to assume that he did not experience head trauma due to his serious in-service fall. As support of this conclusion, the physician highlighted that the Veteran later complained of memory loss while on active duty. The physician also noted that the November 2011 examination showed a diagnosis of TBI. However, the physician commented that the residuals of the TBI were debatable, specifically whether his subjective symptoms were related to a TBI or to his service-connected depression. No further comment was provided with regards to the residual of the in-service TBI and the physician did not discuss the opinions provided in the November 2011 examination report. Thus, the November 2012 examiner did not reconcile the conflicting medical evidence of record or provide a definitive opinion regarding whether the Veteran currently has a residual condition due to his in-service fall. Given the inadequacies found in the November 2011 examination report and November 2012 addendum, the Veteran must be afforded a new VA examination to in order to ascertain the exact nature and etiology of his claimed memory loss disorder. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.). As for the Veteran's remaining claim, the Board again notes that the claim for a TDIU is inextricably intertwined with the issue of entitlement to service connection for residuals of a head injury. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other.) According, the TDIU claim is remanded along with the service connection claim. In this regard, the Board notes that the Veteran's representative submitted an opinion from a private vocational consultant in April 2013, who opined that the Veteran is totally unable to work due to his service-connected low back and headaches disabilities. The RO has not considered this evidence. Thus, on remand, the RO must review this evidence and undertake any additional development deemed appropriate. Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate development to obtain all outstanding VA treatment records and private medical records identified by the Veteran as relevant to the issues being remanded. 2. Thereafter, schedule the Veteran for an appropriate VA examination(s) to assess the nature and etiology of the claimed residuals of head trauma, to include memory loss. The examination should be scheduled with an appropriate clinician that has not yet examined the Veteran with respect to this claim. The entire claims file and any pertinent evidence contained in Virtual VA that is not contained in the claims file must be made available to and reviewed by the examiner(s). All necessary tests and studies, to include diagnostic testing, should be performed, and all findings must be reported in detail. The examiner(s) shall identify all residuals of head trauma found on examination. For all diagnoses made, the examiner(s) must provide an opinion as to the following: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran has any residual disorders or symptoms etiologically related to the May 1987 fall he suffered while on active duty. Specifically, the examiner(s) must discuss whether the Veteran's reported memory loss is a residual disorder/symptom related to the May 1987 fall. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's reported memory loss is etiologically related to a service-connected disability, to include his depressive disorder disability. (c) Whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed disorder is otherwise related to the Veteran's military service. In providing the requested opinions, the examiner(s) must acknowledge and discuss the Veteran's competent reports regarding the onset and progression of the claimed disorder since his military service. The examiner(s) must also consider and reconcile any additional opinions of record, to include the November 2011 and November 2012 VA opinions, or any contradictory evidence regarding the above. The examiner(s) must provide a complete rationale for all opinions offered in a legible report. If the examiner(s) is unable to provide any requested opinion, he or she should explain why an opinion cannot be reached. 3. After completion of the above, the RO/AMC must review the claims file and ensure that the foregoing development actions, as well as any other development that may be in order, has been conducted and completed in full. If any examination report is deficient in any manner, the RO/AMC must undertake corrective action. 4. Regarding the TDIU claim, the RO/AMC shall undertake any additional development deemed necessary, especially in light of the private opinion provided in April 2013. 5. Then, the RO or the AMC shall readjudicate the Veteran's claims. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be provided with a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board for further appellate action. 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). ______________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs