Citation Nr: 1333031 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 06-30 697 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for psychiatric symptoms due to undiagnosed illness. 2. Entitlement to an initial rating in excess of 10 percent for gastrointestinal symptoms due to undiagnosed illness. 3. Entitlement to an initial rating in excess of 10 percent prior to November 18, 2011, and in excess of 30 percent from November 18, 2011, for headaches due to undiagnosed illness. REPRESENTATION Appellant represented by: Joseph R. Moore, Attorney at Law WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from March 1986 to April 1990, from January 1991 to August 1991, and from October 2001 to October 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. During the course of the appeal, the Veteran was awarded an increased evaluation of 30 percent for his headaches, effective November 18, 2011. See January 2012 rating decision. Applicable law mandates that when a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran has not expressed satisfaction with the assigned 30 percent rating for his headaches, the Board concludes that the issue remains on appeal. In October 2009, the Veteran and his wife testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. A Board decision in September 2011 awarded an increased initial rating of 50 percent for the Veteran's psychiatric symptoms due to undiagnosed illness; denied initial ratings in excess of 10 percent for joint pain due to undiagnosed illness and gastrointestinal symptoms due to undiagnosed illness; and remanded an initial rating in excess of 10 percent for headaches due to undiagnosed illness. The Veteran thereafter appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court) insofar as the Board concluded that an initial rating in excess of 50 percent, but no higher, for psychiatric symptoms due to undiagnosed illness was warranted, and that a rating in excess of 10 percent for gastrointestinal symptoms due to undiagnosed illness was not warranted. In an Order dated in July 2012, the Court granted a Joint Motion for Partial Remand (JMPR) by the Veteran and VA General Counsel, which was incorporated by reference, to partially vacate the Board's decision as to the initial ratings assigned to the psychiatric symptoms and gastrointestinal symptoms and remand the case for readjudication in accordance with the JMPR. The Board remanded the issue of an initial rating in excess of 10 percent for headaches due to undiagnosed illness to afford the Veteran a new VA examination. Review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran has submitted new evidence in the form of medical records and employment records, which relate to the issues on appeal. The Veteran specifically waived his right to have the RO consider this evidence in the first instance. 38 C.F.R. § 20.1304(c) (2012). FINDINGS OF FACT 1. The psychiatric symptoms due to undiagnosed illness are manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment thinking, and mood, due to such symptoms as impaired impulse control; obsessional rituals which interfere with routine activities; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships. Total occupational and social impairment has not been shown. 2. Prior to June 30, 2009, the gastrointestinal symptoms due to undiagnosed illness had not resulted in severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress; and had not resulted in chronic gastritis with multiple small eroded or ulcerated areas and symptoms. 3. Since June 30, 2009, the gastrointestinal symptoms due to undiagnosed illness include chronic gastritis with multiple small eroded areas and symptoms. 4. Prior to November 2, 2009, the headaches due to undiagnosed illness had not resulted in characteristic prostrating attacks occurring on an average once a month over the last several months. 5. Since November 2, 2009, the headaches due to undiagnosed illness consist of characteristic prostrating attacks occurring on an average once a month over the last several months but are not manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 70 percent, but no higher, for psychiatric symptoms due to undiagnosed illness have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9434 (2013). 2. Prior to June 30, 2009, the criteria for an initial rating in excess of 10 percent for gastrointestinal symptoms due to undiagnosed illness have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.114 Diagnostic Codes (DCs) 7307, 7319 (2013). 3. Since June 30, 2009, the criteria for a rating of 30 percent, but no higher, for gastrointestinal symptoms due to undiagnosed illness have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.114 Diagnostic Codes (DCs) 7307, 7319 (2013). 4. Prior to November 2, 2009, the criteria for an initial rating in excess of 10 percent for headaches due to undiagnosed illness have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a Diagnostic Code (DC) 8100 (2013). 5. From November 2, 2009, the criteria for a rating of 30 percent, but no higher, for headaches due to undiagnosed illness have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a Diagnostic Code (DC) 8100 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The 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. 2012); 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 representative 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). The notice 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. Such notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was notified in letters dated in November 2000 and May 2003 regarding the type of evidence necessary to establish his claims. The Veteran was notified of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. In addition, a June 2006 letter notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the Veteran's claims for higher initial ratings for his psychiatric symptoms, gastrointestinal symptoms and headaches all due to undiagnosed illness arise from his disagreement with the initial ratings following the grant of service connection. Courts have held that 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). Regardless, the June 2006 letter informed the Veteran of the criteria for assigning a disability rating. See Dingess/Hartman, 19 Vet. App. 473. Regarding VA's duty to assist, VA obtained the Veteran's service treatment records (STRs), personnel records, post-service medical records, and also secured examinations in furtherance of his claims. Pertinent VA examinations were obtained in September 2001, January 2010, November 2010, May 2011 and November 2011. 38 C.F.R. § 3.159(c)(4). The VA examinations obtained in this case are sufficient, as the examiners conducted complete examinations, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disorders. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. A distinction must be made between a veteran's dissatisfaction with original ratings and dissatisfaction with determinations on later filed claims for increased ratings. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Psychiatric Symptoms due to Undiagnosed Illness This service-connected disability is rated as 30 percent disabling under 38 C.F.R. § 4.130, DC 9434, which evaluates impairment from major depressive disorder. Specifically, pursuant to DC 9434, a 30 percent evaluation is warranted if the evidence establishes that 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). 38 C.F.R. § 4.130, DC 9434 (2013). A 50 percent evaluation is warranted if the evidence establishes there is occupational and social impairment, with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted if the evidence establishes there is 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if the evidence establishes there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the rating formula is not intended to constitute an exhaustive list, but rather shows examples of the types and degrees of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) is 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 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). A GAF score of 61 to 70 is indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51 to 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers). A GAF score of 41 to 50 is indicative of 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). The Veteran was afforded a VA examination in September 2001. He reported noticing increasing short term memory loss and difficulty in concentrating. He was alert, oriented to time, person and place, and appropriate. A treatment record in September 2002 shows that the Veteran reported having very low tolerance and easily becoming angry with anyone. He reported having little patience with his children, often yelling at them and often getting angry with his wife and yelling at her. The record indicates that the Veteran gave the impression that the family had to walk on eggshells around him because they were uncertain how he would act. Examination shows that he was adequately groomed, tense and speech was somewhat pressured and angry. He denied any suicidal ideation. The Veteran was afforded a VA examination in January 2010. Examination revealed that he was clean and casually dressed. Psychomotor activity included persistent mannerisms, restless and tense. Speech was spontaneous and rapid; attitude was cooperative and irritable; affect was appropriate and full; mood was agitated; attention was intact; he was oriented to person, time and place; thought process and thought content were unremarkable; there were no delusions; he understand the outcome of his behavior; and he understood that he had a problem. The Veteran had sleep impairment. There were no delusions. He had inappropriate behavior and obsessive/ritualistic behavior. He had no panic attacks and there were no homicidal or suicidal thoughts. He had poor impulse control with episodes of violence. He was able to maintain minimum personal hygiene. There was no problem with activities of daily living. Remote memory was normal, but recent and immediate memory was mildly impaired. The Veteran was employed full time as a firefighter and emergency medical technician (EMT). Occupational problems included inappropriate behavior, increased absenteeism, increased tardiness and memory loss. The Veteran reported that he tried not to go to work when he was feeling poorly. He reported having had physical altercations with some of his co-workers. The Veteran admitted that he would probably lose his job in a day if he had to go to work in an office and be professional. A GAF score of 66 was assigned. The examiner commented that the Veteran had been married to his wife for 17 years and that they got along pretty well. "Okay" was how the Veteran described his relationship with his wife and children. He was estranged from his sister. The examiner opined that there was reduced reliability and productivity due to mental disorder symptoms. At a VA examination in May 2011, the Veteran reported panic attacks three to four times a week; nightmares with military related content; isolating a lot; problems with anger, though he tried to avoid hitting others; and continuing problems with hypervigilance, especially in public. Examination revealed that he was clean and unshaven for a couple of days; psychomotor activity and speech were unremarkable; attitude was cooperative; affect was normal; mood was good; attention was intact; he was oriented to person, time and place; thought process and thought content were unremarkable; there were no delusions; he understood the outcome of his behavior and that he had a problem. He had sleep impairment. He had no hallucinations, inappropriate behavior or obsessive/ritualistic behavior. He had panic attacks. There were no homicidal or suicidal thoughts. His impulse control was good with no episodes of violence. He was able to maintain minimum personal hygiene and there was no problem with activities of daily living. The examiner commented that the Veteran disliked being around a lot of people. Remote memory was normal and recent and immediate memory was mildly impaired. He continued to be employed as a firefighter. A GAF score of 65 was provided. The examiner commented that there was reduced reliability and productivity due to mental disorder symptoms. A private evaluation dated in May 2013 shows that it was the examiner's opinion that the Veteran only worked because of the tolerance of his employer in mitigating the severe psychiatric illness of a disabled veteran. The examiner also opined that beyond his occupational dysfunction, the Veteran had become completely impaired socially outside of the job environment. He had had violent episodes in 2004 and 2009. They opined that the Veteran's symptoms were severe. The Veteran reported that he concurred with his supervising officers who found him irritable, angry, dangerous, violent, aggressive and unable to maintain a consistent level of functionality. The Veteran described his home environment and social life to be virtually nonexistent. He struggled with the most basic of day-to-day interactions with others, was described by his family as unpredictable and dangerous, and described a life where he had no hope that he would ever get better or improve. Examination revealed that the Veteran's speech was decreased in rate, tone and volume with periods of anger and increased volume and intensity of his speech. His mood he said was "okay" and affect was labile at times, but for the most part, constricted, dysphoric and angry. His thought content was positive for intermittent passive suicidal ideation without plan or intent. He did express periods of overt homicidal ideation directed in individuals, but not at the time of that examination. He did not express any delusions or illusions. Thought processing was not linear and logical, but would be considered perseverative and circumstantial. There was no evidence of ongoing perceptual alterations such as auditory, visual or tactile hallucinations. The Veteran was cognitively intact. A GAF score of 40-45 was assigned. The Veteran's employment records indicate several occasions of missing work due to psychiatric illness; however, records in April 2011 show that the Veteran was able to work with no restrictions. A record in September 2012 reveals that the Veteran was unable to fulfill his duties as a firefighter based on limitations for his structural back disease. They also reflect anger problems at work. While the Veteran's employment records show missed work and anger, they fail to show total occupational impairment due to his psychiatric symptoms. Treatment records dated through 2013 do not reflect symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. As they do reflect problems with anger and irritability, they are suggestive of persistent danger of hurting oneself or others. Based on a review of the evidence, the Board concludes that an initial rating of 70 percent, but no higher, is warranted. The evidence shows symptoms such as impaired impulse control; obsessional rituals which interfere with routine activities; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships. As such, the Board concludes that the Veteran's psychiatric symptoms due to undiagnosed illness more clearly approximate the criteria for a 70 percent rating. However, the evidence is not supportive of a finding of a 100 percent rating. Throughout this appeal, the Veteran has remained employed and married. While he does have occupational impairment and his employer may make accommodations for him, the evidence does not show total occupational impairment. The Board acknowledges that the May 2013 evaluation indicates that the Veteran should not be employed and is only working due to "the tolerance of his employer in mitigating the severe psychiatric illness" of the Veteran. However, the overall evidence of record, including the Veteran's employment records, do not show that he has total impairment due to his psychiatric symptoms. In this case, the Board is assigning a 70 percent rating due to occupational impairment with deficiencies in most areas such as work, compensating the Veteran for the occupational impairment shown by the evidence of record. The evidence also does not show total social impairment. The Veteran has remained married throughout this appeal. The Board acknowledges that the evidence shows that the Veteran's family relationships have problems due to his anger and irritability. However, the 70 percent rating takes into account deficiencies in family relations. The Board also acknowledges the May 2013 evaluation showing that the Veteran described his home environment and social life to be virtually nonexistent. However, the Board reiterates that the Veteran has maintained relationships with his family, weighing against a finding of total social impairment. Furthermore, symptoms indicative of a 100 percent rating such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name have not been shown. As noted above, while the Veteran's anger problems are suggestive of persistent danger of hurting oneself or others, the overall symptomatology shown during this appeal are not consistent with total occupational and social impairment, which is required for a 100 percent rating. In this case, the symptoms shown in the treatment records and examinations do not equate to the symptoms contemplated for by a 100 percent rating. Further, the reported GAF score of 40-45 in May 2013 is indicative of serious symptoms, which are consistent with a 70 percent rating. Although the Veteran has been shown to have GAF scores as high as 66 during this appeal, which is indicative of moderate symptoms, the totality of the evidence indicates that the Veteran's symptoms more closely approximate the criteria for a 70 percent rating. While important, the GAF scores assigned in a case are not dispositive of the evaluation and must be considered in light of the actual symptoms of the Veteran's disorder. 38 C.F.R. § 4.126(a). In this case, the extent and severity of the Veteran's actual PTSD symptoms reported and/or shown are suggestive of occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to such symptoms as impaired impulse control; obsessional rituals which interfere with routine activities; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships; i.e., the level of impairment contemplated in a 70 percent rating for psychiatric disabilities. Accordingly, and based on this evidentiary posture, the Board concludes that the totality of the evidence of record has shown that the Veteran's psychiatric symptoms due to undiagnosed illness warrant a rating of 70 percent, but no higher, since the award of service connection. The Board finds, therefore, that the evidence of record does support the schedular criteria required for a rating of 70 percent, but no higher, for this service-connected disability. 2. Gastrointestinal Symptoms due to Undiagnosed Illness This service-connected disability is rated as 10 percent disabling under 38 C.F.R. § 4.114, DC 7319, which evaluates impairment from irritable colon syndrome (spastic colitis, mucous colitis, etc.). Specifically, pursuant to DC 7319, a 10 percent evaluation is warranted for moderate disability with frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. § 4.114, DC 7319 (2013). A 30 percent evaluation is warranted for severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Id. As the evidence shows that the Veteran has gastritis, the Board will also consider the applicable diagnostic code for that disability. Gastritis is rated under 38 C.F.R. § 4.114, DC 7307. Specifically, pursuant to DC 7307, a 10 percent evaluation is warranted for chronic gastritis with small nodular lesions, and symptoms. 38 C.F.R. § 4.114, DC 7307 (2013). A 30 percent evaluation is warranted for chronic gastritis with multiple small eroded or ulcerated areas, and symptoms. Id. A 60 percent evaluation is warranted for chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas. Id. With regard to coexisting abdominal conditions, VA regulation recognizes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113 (2013). Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Id. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Board also notes that, with regard to the schedule of ratings for the digestive system, section 4.114 expressly prohibits, in pertinent part, the combination of ratings under diagnostic codes 7301 to 7329, inclusive, which include the schedular criteria DCs 7307 and 7319. The Veteran was afforded a VA examination in September 2001. He reported loose brown stools, usually twice a day without melena or hematochezia but associated with some abdominal cramping. He reported no weight loss. A private treatment record in June 2009 shows a diagnosis of gastritis. Diagnostic testing on June 30, 2009, revealed multiple antral erosions. At his October 2009 hearing, the Veteran testified that he had diarrhea every day. October 2009 Hearing Transcript (T.) at 9. He testified having cramping issues and being treated for acid reflux. Id. At a January 2010 VA examination, the Veteran reported having diarrhea once a day. He reported that two or three times, he had three to four loose bowel movements per day. He reported that sometimes there was blood due to recurrent hemorrhoids. He reported that a polyp had been found on a colonoscopy. The Veteran reported that he felt that his heartburn was part of his lower gastrointestinal claim and that he took medication with good relief. He reported that without medication, he would have symptoms 24/7. The Veteran reported never having any medical evaluation for diarrhea in particular. He reported that once he inadvertently soiled his drawers when he thought he was only passing gas. The Veteran reported taking medication about two to three times per week for diarrhea. The examiner opined that the Veteran's diarrhea had no significant effects on his usual occupation and usual daily activities. The Veteran reported that when his diarrhea flared up, he had to be close to a toilet. The examiner opined that a simple change in diet might result in firm stools. The examiner also commented that the Veteran did not have chronic diarrhea. The examiner reported that one loose stool per day and several loose stools several days per week did not qualify as chronic diarrhea. A November 2010 VA treatment record shows that diagnostic testing in 2004 and 2009 were reviewed. The testing in 2004 showed a polyp; otherwise, the colonoscopy was negative. A colonoscopy in 2009 was reportedly normal. The June 2009 treatment record showing gastritis was reported. The conclusion was that there were no abnormal findings indicative of colon dysfunction; such abnormal findings would be expected if there were a colonic problem or chronic diarrhea. Thus, the documentation did not confirm a diagnosis of any chronic diarrheal condition based on colonic anatomy. Gastritis was diagnosed; the physician who wrote the note indicated that that would not cause diarrhea. A record dated in May 2012 show that the Veteran had dyspepsia. The Veteran's treatment records during this appeal dated through 2013 have not shown severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. While the Veteran's diarrhea is documented, more or less constant abdominal distress has not been shown. The Veteran's employment records show several occasions of missing work for other service connected disabilities, but not for his gastrointestinal symptoms. Prior to June 30, 2009, the records also do not show chronic gastritis with multiple small eroded or ulcerated areas, and symptoms. Since June 30, 2009, the records do not show chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas. Based on a review of the evidence, the Board concludes that a rating of 30 percent is warranted, effective June 30, 2009. Prior to June 30, 2009, an initial rating in excess of 10 percent is not warranted. Prior to June 30, 2009, the next higher rating of 30 percent under DC 7319 requires severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. The VA examinations and treatment records during this period have not shown more or less constant abdominal distress. No medical professional has opined that the Veteran's disability was severe. The Veteran's treatment records reflect constant psychiatric treatment, but do not show as much gastrointestinal treatment, weighing against a finding that his disability is severe. Therefore, an initial rating in excess of 10 percent under DC 7319 is not warranted. As for DC 7307, a 30 percent rating requires chronic gastritis with multiple small eroded or ulcerated areas, and symptoms. In this case, the earliest evidence of chronic gastritis with multiple small eroded or ulcerated areas, and symptoms, was in June 30, 2009. As the evidence of record did not reflect such disability prior to that time period, an initial rating in excess of 10 percent prior to June 30, 2009, is not warranted. However, as the June 30, 2009, diagnostic testing revealed gastritis with multiple antral erosions, the Board concludes that a 30 percent rating is warranted. The Board also finds that the next higher rating of 60 percent is not warranted as the evidence does not show chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas. While the Veteran has chronic gastritis, severe hemorrhages or large ulcerated or eroded areas have not been shown. Therefore, the Board concludes that a rating of 30 percent, but no higher, for gastrointestinal symptoms due to undiagnosed illness is warranted effective June 30, 2009. The Board has also considered whether a higher rating is warranted under other diagnostic codes used to evaluate gastrointestinal disabilities. However, a review of DCs 7200 through 7354 shows that DCs 7307 and 7319 are the most applicable due to the Veteran's pertinent diagnosis of gastritis as well as the symptoms associated with his service-connected disability. Therefore, the Board concludes that higher ratings under other diagnostic codes used to evaluate gastrointestinal disabilities are not warranted. Accordingly, and based on this evidentiary posture, the Board concludes that the totality of the evidence of record has shown that the criteria for an initial rating in excess of 10 percent prior to June 30, 2009, have not been met. From June 30, 2009, the criteria for a 30 percent rating, but no higher, have been met. 3. Headaches This service-connected disability is rated as 10 percent disabling prior to November 18, 2011, and as 30 percent disabling from November 18, 2011, under 38 C.F.R. § 4.124a, DC 8100, which evaluates impairment from migraine headaches. Specifically, pursuant to DC 8100, a 10 percent rating is warranted for characteristic prostrating attacks averaging one in two months over last several months. 38 C.F.R. § 4.124a, DC 8100 (2013). A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. Id. A 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. The rating criteria do not define "prostrating," nor has the Court. The Board notes, however, that DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), defines "prostration" as "extreme exhaustion or powerlessness." Similarly, WEBSTER'S II NEW COLLEGE DICTIONARY 889 (3rd Ed. 2001), defines the term as "physically or emotionally exhausted; INCAPACITATED." The Veteran was afforded a VA examination in September 2001. He reported headaches with no scotomata or neurological symptoms and no associated nausea or vomiting. He reported that his headaches lasted up to two hours and were relieved with medication when they occurred four to five times per month, currently decreasing somewhat in the frequency. A neurology consultation dated November 2, 2009, shows that the Veteran reported two headaches a week that could last anywhere from one to three hours. He generally needed to lie down because of severe photophobia and inability to function. He did not have any nausea or vomiting. At a January 2010 VA examination, the Veteran reported that headaches occurred weekly and were treated with continuous medication. Most attacks were prostrating and lasted for hours. The examiner opined that the Veteran's headaches had a significant effect on his usual occupation due to increased absenteeism. The Veteran reported that he had called out of work about three days in the past year due to headaches. The Veteran was afforded a VA examination in May 2011. He reported having headaches about two to three times a week at worst, now down to one to two times per week on his current medication regime. He reported that his headaches lasted about one and a half hours on the medication. He reported that associated symptoms included dizziness, emesis, anxiety and photo/phono-phobia. The Veteran reported flare-ups of headaches that were severe and lasted up to two days. Flare-ups reportedly included pain, weakness, fatigue and functional loss as evidenced by work absences. The examiner opined that the Veteran's migraines could be prostrating in nature as evidenced by the need to miss work. The Veteran was also afforded a VA examination in November 2011. He reported taking medication about four times a month and that he had incomplete relief if he took the medication early in the headache course. The Veteran reported that his headaches were characterized by the initial onset of nausea followed by bilateral constant pain over his head. He reported blurring of his vision, nausea, occasional vomiting, sensitivity to light and sound, and was worsened with physical activity. He needed to find a dark place and lie down for a few hours before his headaches began to improve. The Veteran's associated symptoms included nausea, sensitivity to light and sound, and changes in vision (such as scotoma, flashes of light, tunnel vision). His headaches typically lasted less than one day. The Veteran reportedly had characteristic prostrating attacks more frequently than once per month. The examiner reported that the Veteran did not have very frequent prostrating and prolonged attacks of migraine headache pain. The examiner also reported that the Veteran did not have prostrating attacks of non-migraine headache pain. The examiner opined that the Veteran's headache condition impacted his ability to work; he had had approximately ten absences over the past year because of headaches and that had caused tension at work. The examiner opined that the Veteran's typical episodes about four times a month left him prostrate; that is, lying down for several hours, fulfilling the definition of prostration. The Veteran's treatment records during this appeal dated through 2013 do not show very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Records dated prior to the January 2010 VA examination did not show characteristic prostrating attacks occurring on an average once a month over the last several months. The Veteran's employment records confirm that the Veteran experienced migraines in December 2010, January 2011, March 2011, June 2011, July 2011 and August 2011. A record dated in June 2012 shows that the Veteran reported missing five days of work due to migraines between May 2012 and June 2012. Based on a review of the evidence, the Board concludes that a rating of 30 percent is warranted, effective November 2, 2009. Prior to November 2, 2009, an initial rating in excess of 10 percent is not warranted. The September 2001 VA examination and treatment records dated prior to the November 2, 2009, neurology consultation do not show characteristic prostrating attacks occurring on an average once a month over the last several months. As noted above, the Veteran reported no associated symptoms such as scotomata, neurological symptom, nausea or vomiting in September 2001. He also reported that they were relieved with medication. The Veteran's treatment records for this time period do not show that he sought treatment for prostrating headaches or that he reported having prostrating attacks. As noted above, the November 2011 examiner reported that lying down for several hours fulfills the definition of prostration. The Veteran's treatment records during this time period do not show that he had headaches resulting in lying down for several hours on an average once a month over the last several months. Therefore, the criteria for an initial rating in excess of 10 percent prior to November 2, 2009, have not been met. From November 2, 2009, the evidence supports a finding of a 30 percent rating. In this case, the November 2, 2009, neurology consultation shows that the Veteran needed to lie down because of severe photophobia and inability to function. His headaches reported occurred twice a week. Therefore, the criteria for a 30 percent rating due to characteristic prostrating attacks occurring on an average once a month over the last several months have been met. However, the evidence does not support a finding that the highest rating of 50 percent is warrant. A 50 percent rating is assigned for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In this case, the VA examinations and treatment records since November 2, 2009, do not show such attacks. Even if the Veteran's characteristic prostrating attacks are very frequent, they have not been shown to be productive of severe economic inadaptability. The Board acknowledges that the Veteran's employment records show that he missed work due to his migraines. However, even with his migraines, he was still able to work. Severe economic inadaptability has not been shown; no medical professional has provided any opinion indicating such impairment. Accordingly, and based on this evidentiary posture, the Board concludes that the totality of the evidence of record has shown that the criteria for an initial rating in excess of 10 percent prior to November 2, 2009, have not been met. From November 2, 2009, the criteria for a 30 percent rating, but no higher, have been met. 4. Extraschedular Consideration Furthermore, the rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the disability. 38 C.F.R. § 4.1. The Board notes that in exceptional cases where evaluations provided by the rating schedule are found to be inadequate, an extraschedular evaluation may be assigned which is commensurate with the veteran's average earning capacity impairment due to the service-connected disorder. 38 C.F.R. § 3.321(b). However, the Board believes that the regular schedular standards applied in the current case adequately describe and provide for the Veteran's psychiatric, gastrointestinal and headache symptoms and disability level. Marked interference with employment beyond that contemplated by the schedular criteria has not been shown. The record does not reflect a disability picture that is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the Veteran for his service-connected disabilities. The evidence does not show that the Veteran's psychiatric, gastrointestinal and headache symptoms have resulted in interference with employment or activities of daily life which would warrant increased ratings for these disabilities beyond the schedular increases granted in this decision. Moreover, the evidence does not show that these disabilities render him unemployable. Although the Veteran has been shown to miss work and is accommodated by his employer, he has still been able to remain gainfully employed throughout this appeal, except in 2012 when back issues, which are not service-connected, left him temporarily unable to work. Therefore, the issue of entitlement to a total disability rating based on individual unemployability has not been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER Entitlement to an initial 70 percent rating, but no higher, for psychiatric symptoms due to undiagnosed illness is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 10 percent prior to June 30, 2009, for gastrointestinal symptoms due to undiagnosed illness is denied. Entitlement to a rating of 30 percent, but no higher, from June 30, 2009, for gastrointestinal symptoms due to undiagnosed illness is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 10 percent prior to November 2, 2009, for headaches due to undiagnosed illness is denied. Entitlement to a rating of 30 percent, but no higher, from November 2, 2009, for headaches due to undiagnosed illness is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs