Citation Nr: 1330880 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 04-26 812 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a respiratory disorder (previously claimed as mild restrictive disease), to include as secondary to in-service asbestos exposure. 2. Entitlement to an initial rating in excess of 30 percent for a generalized anxiety disorder and major depression, prior to January 29, 2013. 3. Entitlement to an initial rating in excess of 10 percent for mixed headaches consisting of chronic daily and vascular etiology, prior to January 29, 2013. 4. Entitlement to an initial rating in excess of 30 percent for mixed headaches consisting of chronic daily and vascular etiology, since January 29, 2013. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1971 to June 1974. The respiratory claim comes before the Board of Veterans' Appeals (Board) from an April 2003 rating decision of the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which denied the benefit sought on appeal. The Veteran then perfected a timely appeal of this claim. The generalized anxiety disorder and headaches claims come before the Board from a January 2010 rating decision of the RO in Winston-Salem, North Carolina, which denied a disability rating in excess of 10 percent for the headaches and which denied a disability rating in excess of 30 percent for the generalized anxiety disorder and major depression. The Veteran then perfected a timely appeal of these claims. The Board notes that the Veteran requested a hearing before the Board at his local VA office in July 2004, with respect to his respiratory disorder claim. A hearing was scheduled for September 2004. In a subsequent written communication, the Veteran indicated that he wished to withdraw his hearing request. Thus, his hearing request is deemed withdrawn. 38 C.F.R. § 20.704(e) (2013). In March 2007 and February 2010, the Board remanded the respiratory disorder claim for further development. In November 2012, the Board remanded the respiratory disorder, headaches, and generalized anxiety disorder claims to the RO via the Appeals Management Center (AMC), in Washington, DC, for further development. Upon remand, the AMC issued another rating decision in March 2013, which increased the disability rating for the headaches to 30 percent and which increased the disability rating for the generalized anxiety disorder and major depression to 100 percent. The increased ratings were made retroactively effective from January 29, 2013, the date of VA examinations. This rating decision created staged disability ratings, and the Board has recharacterized the title page accordingly. The Veteran has continued to appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (indicating that a Veteran is presumed to be seeking the highest possible rating unless he or she expressly indicates otherwise). Additionally, in regard to the AMC's award of a 100 percent rating, the Board observes that in the March 2013 rating decision, the AMC found that this rating decision was a full grant of the benefits on appeal, and thus found that this issue was no longer on appeal. This is an incorrect statement. Following the 100 percent grant, the issue of entitlement to a rating in excess of 30 percent for a generalized anxiety disorder and major depression, prior to January 29, 2013, remained on appeal. See AB, 6 Vet. App. at 38-39 (1993) (indicating that a Veteran is presumed to be seeking the highest possible rating unless he or she expressly indicates otherwise). Since the AMC found this issue to no longer be on appeal, the AMC did not provide a SSOC to the Veteran and his representative addressing the issue. The SSOC was requested in the Board's November 2012 remand directives. Normally, if a Veteran has not received an SSOC on an issue, he would be deemed as having been deprived due process in the opportunity to respond to the readjudication of his claim, thereby warranting the remand of his case for issuance of an SSOC. Here, however, given the Board's favorable decision in granting a 100 percent rating all the way back to the date of claim, the procedural error is harmless and a remand is unnecessary. Lastly, the claim of entitlement to service connection for a right foot disorder was previously on appeal before the Board in November 2012, when it was remanded by the Board for further development. However, a subsequent June 2013 rating decision granted that claim. To date, the Veteran has not appealed either the initial disability rating or effective date assigned. Therefore, that claim is no longer before the Board on appeal. See 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 (NOD) must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date); see, too, 38 C.F.R. § 20.200 (2013). The Veteran's Virtual VA records were also reviewed and considered in preparing this decision and remand. The issue of entitlement to service connection for a respiratory disorder is addressed in the REMAND portion of the decision below and is to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The functional impairment caused by the Veteran's service-connected generalized anxiety disorder and major depression more closely approximated total occupational and social impairment prior to January 29, 2013. 2. With resolution of doubt in favor of the Veteran, his service-connected mixed headaches consisting of chronic daily and vascular etiology are productive of symptoms that more nearly resemble headaches that are very frequently completely prostrating with prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for a rating of 100 percent for generalized anxiety disorder and major depression have been met prior to January 29, 2013. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code 9434-9400 (2013). 2. The criteria for a 50 percent rating for service-connected mixed headaches consisting of chronic daily and vascular etiology have been met prior to January 29, 2013 and beginning 29, 2013. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.124a, Diagnostic Code 8199-8100 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. VA's Duties to Notify and Assist Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). As the Board is granting a total rating for the psychiatric disability for the period at issue, the Board need not address whether there has been compliance with the VCAA as that issue is moot. In regard to the Veteran's headache claim, the Board finds that the content requirements of a duty-to-assist notice letter have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The letter from the RO dated in May 2009 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim, as well as an explanation of what evidence was to be provided by him and what evidence VA would attempt to obtain on his behalf. The letter also gave the Veteran information concerning the evaluation and effective date that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claim was last readjudicated in the 2013 Supplemental Statement of the Case (SSOC). The Board finds that the duty to notify provisions have been met. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. His STRs, personnel records, and post-service VA and private treatment records have been obtained. The claims file does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disorder currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. The record indicates that the Veteran participated in VA examinations and medical opinions in October 2009 and January 2013, the results of which have been included in the claims file for review. The Board finds the VA examination reports are adequate for evaluation purposes because the examiners had knowledge of the relevant facts pertaining to the Veteran's medical history, considered the contentions of the Veteran, and provided the information necessary to evaluate the Veteran's disability under the applicable rating criteria. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Given the foregoing, the Board finds that VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. The Board is also satisfied as to substantial compliance with its remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Increased Rating 1. Generalized Anxiety Disorder and Major Depression Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2013). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2013); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2013); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2013); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10 (2013). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider a veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 35 (1999). A veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under the General Rating Formula for Mental Disorders, a 30 percent rating contemplates 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). A 50 percent rating contemplates 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted 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 factors listed in the rating formula are "examples" of conditions that warrant particular ratings as the use of the term "such as" 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 the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2013). The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. Id. Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2013). One factor for consideration is the GAF score, which is based on a scale reflecting the "psychological, social, and occupational functioning in 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 (4th ed.), p.32.). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). When it is not possible to separate the effects of the service-connected condition and the nonservice-connected condition, VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, dictate that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In a January 2010 rating decision, the RO granted service connection for generalized anxiety disorder and major depression and granted a 30 percent evaluation effective April 14, 2009, the date of receipt of the Veteran's original claim for service connection. The assigned evaluation was based on findings provided at an October 2009 QTC examination. At the October 2009 examination, the Veteran reported that his anxiety and depression were constant. His symptoms affected his total daily functioning which resulted in him not being able to take joy in his life. Each day he worried and suffered. He had a highly stressed marriage. He had had trouble sleeping for the past 26 years. He also experienced night sweats. He had symptoms of excessive worrying with high levels of anxiety and general fearfulness. His worrying appeared to control him. He was restless and on edge. He had difficulty concentrating and was highly irritable. He had muscle tension and sleep disturbances. His symptoms of depression included feeling hopeless and helpless. He had passive thoughts of deaths and he felt overwhelmed. He had his wife drive him to work for fear that he would run the car into a tree and kill himself. He rated his depression an 8.5. He was unable to take joy in his life and its events. Since leaving the service he has worked as a boiler operator for over 20 years. The relationship with his supervisor and co-workers is fair. During this employment he experienced irritability; he might "snap" at others. His relationship with his parents is good. His relationship with his children is distant. He does not like being around others. He is a recluse. He goes to work and then comes home. His family is stressed by his symptoms. The examiner maintained that the Veteran was a reliable historian. On mental status examination, the Veteran's orientation was within normal limits. His appearance, hygiene, and behavior were appropriate. He maintained good eye contact during the exam. His affect and mood showed anxiety. His affect and mood exam indicated a depressed mood which occurred near-continuously and did not affect the ability to function independently. He had intermittent suicidal ideation. He felt hopeless and helpless. He had passive thoughts of death and would like to have God end his suffering. He was highly anxious and easily set off. Communication was within normal limits. Speech was within normal limits. He showed impaired attention and/or focus. He was highly anxious and easily distracted from ongoing events or conversations. Panic attacks were present and occurred more than once per week. During the attacks he experienced anxiety, pounding heart, sweating, and flushing. The examiner maintained that there were also signs of suspiciousness due to the following: the Veteran was very suspicious of the motives and intentions of others; he reported that this was why he had no male friends. There was no history of delusions or hallucinations and obsessional rituals were absent. Thought processes were appropriate. He was able to read and understand directions. He did not have slowness of thought and he did not appear confused. Judgment was not impaired. Abstract thinking was normal. Memory was impaired and the degree was mild-he forgot names, directions, and recent events. Homicidal ideation was absent. The examiner provided diagnoses of generalized anxiety disorder and major depression on Axis I and assigned a GAF score of 50. The examiner maintained that the best description of the Veteran's impairment is psychiatric symptoms that cause occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. Additionally, VA treatment records show that in August 2009, the Veteran was experiencing current thoughts of suicide, and he was exhibiting fair impulse control and judgment, and fair to shaky insight. He continued to demonstrate "vague" suicidal ideations although with no plan or intent in December 2009, January 2010, January 2011, and March 2011. In the Veteran's November 2011 VA Form 9, he maintained that he had to leave work early more often due to the shakiness that he felt inside. His treating physician has continued to increase his Citalopram Hydrobromide to 40 mg daily due to increased nightmares, panic attacks, and impaired memory along with preoccupation with death and suicide. Thereafter, the Veteran underwent another VA examination in January 2013. The Veteran complained of anxiety with accompanying shakes and sweats, and he experienced a lot of tremors. He experienced excessive worrying which happened on a daily basis and generally interfered with his overall functioning. He experienced sleep disturbances on a daily basis and had nightmares. He was really moody and irritable. He got into arguments rather easily which caused problems in his personal relationships. He was in the process of getting divorced. He also had problems getting along with people that he had worked with. He no longer worked. He did miss time from work due to his emotional problems. He had been out of work for 13 months due to multiple health problems and the tremors. He was also depressed and at these times did not want to be around people. He was withdrawn for days at a time and tended to ignore his grooming habits and he admitted to suicidal thoughts but never made any attempts. He did not do many things particularly fun activities which the examiner maintained would seem to interfere with his ability to be gainfully employed. The Veteran further indicated that he did see his children but he had no friends. He lived with his brother and he did not socialize much. The examiner maintained that the Veteran's disability was manifested by the following: depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; suicidal ideations; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. On mental status examination, the examiner observed that the Veteran appeared casually dressed. His speech was clear, although he stuttered initially. He was oriented in all three spheres. There were no delusions or hallucinations in his thought content, but there was some active suicidal ideation but no plan or intention to act on this. Reasoning and judgment seemed to be adequately intact, and his memory appeared to be intact. His affect was clearly anxious and somewhat depressed. The examiner maintained that the Veteran had generalized anxiety disorder and major depression and assigned a GAF score of 50 indicative of serious symptomatology. The examiner maintained that the Veteran had occupational and social impairment with reduced reliability and productivity. In a March 2013 rating decision, the AMC granted a 100 percent rating effective January 29, 2013, the date of the VA examination. The AMC maintained the grant was based on evidence the Veteran's disability was manifested by the following: intermittent inability to perform activities of daily living; intermittent inability to perform maintenance of minimal personal hygiene; neglect of personal appearance and hygiene; suicidal ideation; occupational and social impairment with reduced reliability and productivity; difficulty in establishing and maintaining effective work and social relationships; disturbances of motivation and mood; flattened affect; panic attacks more than once a week; anxiety; chronic sleep impairment; and depressed mood. The AMC therefore found that the overall severity of the disability more closely approximated the criteria for a 100 percent disability evaluation. In the July 2013 Informal Hearing Presentation, the Veteran's representative argued that the 2009 QTC examination showed the same levels of mental impairment and functioning as in 2013. The Board agrees. Other than evidence that the Veteran occasionally neglects his personal hygiene, the Board finds that the symptomatology otherwise supporting the basis for assigning a 100 percent disability rating is very similar to the symptomatology that has been shown throughout the course of this appeal. The Board finds no clear demarcation line showing the Veteran's generalized anxiety disorder and major depression exhibited distinct symptoms that would warrant different ratings. Throughout the appeal period the Veteran has suffered from chronic anxiety, chronic depression, mood swings, sleep disturbances, and difficulty getting along with people, and he has continuously admitted to suicidal thoughts. Indeed, the Veteran's symptoms were assigned GAF scores of 50 in 2009 and 2013. For these reasons, the Board finds that the Veteran should be assigned a 100 percent rating prior to January 29, 2013. 2. Mixed Headaches Consisting of Chronic Daily and Vascular Etiology The Veteran's service-connected mixed headaches consisting of chronic daily and vascular etiology have been rating by analogy to migraine headaches under 38 C.F.R. § 4.124a , Diagnostic Code 8199-8100 (2013). Under that diagnostic code, a 30 percent rating may be assigned for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months and a 50 percent rating may be assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The record reflects that in a January 2010 rating decision, the RO granted service connection for mixed headaches consisting of chronic daily and vascular etiology and assigned a 10 percent disability rating effective April 14, 2009, the date of receipt of the Veteran's original claim for service connection. The assigned evaluation was based on findings provided at an October 2009 QTC examination. At the 2009 examination, the Veteran complained of throbbing, pounding headaches in the temples around the eyes and back of his head that occurred three times a day lasting four hours, and at times up to three days at a time. He experienced flashing lights, nausea, phonophobia, and photophobia. The headaches interfered with driving at times and social activities at times, walking upstairs, and sleeping. The neurological examination was normal. The examiner observed that the Veteran's treatment records revealed a diagnosis of chronic daily headaches for the past 40 years and analgesia overuse playing a role in perpetuation of muscle contraction, headaches, and vascular headaches. The examiner maintained that the Veteran's headaches were more migraine in nature but the daily representation favored chronic daily headaches. In VA Form 9 dated in November 2011, the Veteran maintained that he continued to experience chronic attacks of migraine. The pain was aggravated by daily activities like walking up stairs. He experienced nausea and at times experienced cold hands and feet along with sensitivity to light. He complained of tremors. He maintained that he experienced prostrating attacks twice weekly. Thereafter, the Veteran underwent another VA examination in January 2013. The Veteran complained that he experienced headaches every day, sometimes two to three times a day. His headaches lasted anywhere from 30 to 45 minutes to 2 hours. When he experienced a headache he would lie down. His headaches were worse in the summer because of the light. The pain was a pulsating, throbbing quality and the location was in the bitemporal and occipital area. Pain worsened with physical activity. The examiner maintained that the Veteran experienced non-headache symptoms associated with his headaches, including nausea, sensitivity to light, and sensitivity to sound, and he also complained of sensory changes such as a pins and needles feeling in his hands and feet. The Veteran reported that he retired from work due to right hand tremors and headaches. When he was working, he stated that approximately six times in six months he would miss work secondary to headaches. He, however, also complained of depression and admitted to staying home a lot secondary to depression and the headaches. The examiner provided a diagnosis of migraine headaches. The examiner maintained that it was very difficult to assess whether the Veteran's headaches were prostrating or non-prostrating headaches, given the Veteran's admission of depression and stating that he stayed home a lot secondary to depression and headaches. Therefore, given the psychology component, the examiner could not determine whether it was the headaches or the depression, or a combination of both. The examiner maintained it was most likely a combination of both that leads the Veteran to stay home a lot, and he did state that when he was working, he missed work about six times in six months. In a June 2013 rating decision, the RO increased the disability rating to 30 percent effective January 29, 2013, the date of the VA examination. The Board observes at the outset that the 2013 VA examiner essentially found that because the Veteran also suffers from such non-headache symptoms as nausea, sensitivity to light, and sensitivity to sound that he indeed also suffered from migraines. The regulations do not define the term "prostrating," but "prostration" is defined as "extreme exhaustion or powerlessness." Kaiser v. Shinseki, No. 08-4039, 2010 WL 675259, at *2 (Vet. App. February 23, 2010) (quoting Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007) (non-precedential). The 2013 VA examiner maintained that it was very difficult to assess whether the Veteran's headaches were prostrating or non-prostrating headaches, given the Veteran's admission of depression and stating that he stayed home a lot secondary to depression and headaches. When it is not possible to separate the effects of the service-connected condition and the nonservice-connected condition, VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, dictate that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Service connection is already in effect for major depression. The Board, however, notes that the Veteran has provided competent and credible lay testimony that the pain he experiences from the migraines is generally aggravated by physical activity thereby necessitating that he lay down. This seems to suggest that the Veteran's attacks are completely prostrating. The Veteran also believes that he experiences sensory changes in association with his migraines. Given the VA examiner's finding and the Veteran's lay testimony, including the frequency (occurring more than once a month) and duration of the migraines, the Board finds that reasonable doubt should be resolved in favor of the Veteran that his symptoms more closely resemble very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability for a 50 percent rating. Additionally, the Board notes that in the July 2013 Informal Hearing Presentation, the Veteran's representative argued that the 2009 QTC examination showed the same level of impairment as in 2013. The Board agrees. The Board finds that the symptomatology supporting the basis for assigning a 50 percent disability rating has been shown throughout the course of the appeal. The Board finds no clear demarcation line showing the Veteran's mixed headaches exhibited distinct symptoms that would warrant different ratings. For these reasons, the Board finds that the Veteran should be assigned a 50 percent rating prior to January 29, 2013 and beginning January 29, 2013. The 50 percent rating is the maximum schedular rating available under Diagnostic Code 8100. Consideration has also been given regarding whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2013); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1)(2012); Thun, 22 Vet. App. at 116. The Veteran has not described any exceptional or unusual features associated with his headache disability that have not been contemplated in the assigned rating. The diagnostic criteria contemplate prostrating attacks productive of debilitating pain warranting rest. The Board's assignment of a 50 percent rating is based in part on lay testimony from the Veteran regarding the symptoms he experiences, including that his migraines are generally aggravated by physical activity necessitating that he lay down, and the duration of his symptoms. Given all of the foregoing, the Board finds that the schedular evaluation in this case is not inadequate. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. ORDER A higher rating of 100 percent for service-connected generalized anxiety disorder and major depression prior to January 29, 2013 is granted, subject to the law and regulations governing the payment of monetary benefits. A higher rating of 50 percent for service-connected mixed headaches consisting of chronic daily and vascular etiology prior to January 29, 2013 and beginning January 29, 2013 is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND Respiratory Disorder Inasmuch as the Board regrets the additional delay of this appeal, a remand is required before the remaining claim can be properly adjudicated. The Veteran seeks service connection for a respiratory disorder, to include as secondary to in-service asbestos exposure. The Veteran has been diagnosed with several respiratory disorders including asthma by his private physician in August 2003, and cough-variant asthma by a May 2013 VA examiner. In the July 2013 Informal Hearing Presentation, the Veteran's representative maintained that panic attacks and anxiety aggravate asthma symptoms. In support of this theory, the Veteran's representative references a website http://www.ncbi.nlm.gov/pubmed/10227264 which notes that "[p]anic and anxiety can directly exacerbate asthma symptoms through hyperventilation." The Board has a duty to address all issues reasonably raised either by the appellant or by the contents of the record. See Robinson v. Peake, 21 Vet. App. 545, 552-56 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). VA must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c)(4)(i) (2013). There is competent evidence of a current disability and an indication that the disability may be associated with the another service-connected disability but none of the opinions of record address whether the Veteran's asthma is secondary to his service connected generalized anxiety disorder. Accordingly, the Board finds it necessary to remand the claim to obtain an opinion. Accordingly, the case is REMANDED for the following actions: 1. Send the claims file to an appropriate examiner for an opinion in regard to the Veteran's claimed respiratory disability. In light of evidence that "[p]anic and anxiety can directly exacerbate asthma symptoms through hyperventilation" (see http://www.ncbi.nlm.gov/pubmed/10227264), the examiner is asked to address whether the Veteran's asthma or cough-variant asthma is at least as likely as not (50 percent or greater probability) (a) caused by or (b) aggravated by the service connected generalized anxiety disorder. The examiner is to accept as fact that the Veteran suffers from panic attacks. If such aggravation is found, the examiner should address the following medical issues: (i) the baseline manifestations of the Veteran's asthma or cough-variant asthma found prior to aggravation; and (ii) the increased manifestations that are proximately due to the service-connected generalized anxiety disorder. If the examiner is unable to answer any question without a resort to speculation, then he or she should so indicate and provide a rationale for why an answer could not be provided. 2. After the above actions have been completed, readjudicate the Veteran's claim. If the claim remains denied, issue to the Veteran and his representative a Supplemental Statement of the Case (SSOC). Afford them the appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs