Citation Nr: 1334239 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-12 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an increased disability evaluation for posttraumatic stress disorder (PTSD), currently rated as 50 percent disabling. 2. Entitlement to an increased disability evaluation for headaches due to head trauma, currently rated as 30 percent disabling. 3. Entitlement to a compensable disability evaluation for scar residual resulting from blast injury to the left flank. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is also the appellant, had active service from June 1999 to July 1999 and from March 2001 to December 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Seattle, Washington, which continued the originally assigned 30 percent disability evaluation for PTSD and the 10 percent evaluation for headaches due to the blast trauma and the noncompensable disability evaluation for the left flank scar. In a September 2010 rating determination, the RO increased the Veteran's disability evaluation for his PTSD from 30 to 50 percent and increased the disability evaluation for the service-connected headaches from 10 to 30 percent disabling, with the effective dates for both disabilities being the date of the Veteran's request for increased ratings. As a result of the RO's action, the Board has listed the issues as such on the title page of this decision. For reasons that will be discussed in the remand portion of the decision below, the issue of an increased (compensable) disability evaluation for residuals of the left flank scar is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the rating period prior to July 25, 2011, the Veteran's PTSD was not characterized by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: obsessional rituals which interfered 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. 2. For the rating period from July 25, 2011, the Veteran's PTSD has caused occupational and social impairment with deficiencies in most areas including difficulties in the work environment, mood problems, impaired impulse control, unprovoked irritability, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective relationships, near continuous depression, lack of energy/motivation, and intrusive thoughts. 3. Throughout the appeal period, the Veteran's headaches have caused characteristic prostrating attacks, but have not caused severe economic inadaptability for any period. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 50 percent for PTSD prior to July 25, 2011 were not met or more nearly approximated. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. Resolving reasonable doubt in favor of the Veteran, the disability criteria for a 70 percent evaluation for PTSD from July 25, 2011 have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a disability evaluation in excess of 30 percent for headaches have not been met or approximated for any time period. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8100 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Evaluations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant 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). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). PTSD The General Formula for Rating Mental Disorders, Diagnostic Code 9411, provides that a 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as (for example only): 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 abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech 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. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation is assigned 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms cited above follow the phrase "such symptoms as" which indicates 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. Accordingly, the Board has not required the presence of all or most of the enumerated symptoms for any particular rating. The list of symptoms merely 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. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM), 32 (4th ed.) (1994) (DSM IV); 38 C.F.R. §§ 4.125 , 4.130 (2012). GAF scores from 71 through 80 is indicative that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more that slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Scores ranging from 61 through 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. Scores ranging from 51 through 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 through 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). A GAF score from 31 through 40 contemplates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran maintains that an evaluation in excess of 50 percent is warranted for his PTSD. He maintains that the symptomatology associated with PTSD, including sleep problems, depression, isolation, anxiety, irritation, being angry, and work pressures when he worked, demonstrate that an evaluation in excess of 50 percent is warranted. In conjunction with his claim, the Veteran was afforded a VA examination in December 2008. At the time of the examination, the Veteran reported having continuing intrusive thoughts of combat situations. He also noted having problems with falling asleep and having terrifying nightmares several times per week. The Veteran reported having continuous irritability and a tendency towards hostile reactions to others. He avoided crowded places and preferred isolation. He was a full-time college student and worked as a waiter in a restaurant. His girlfriend had expressed concerns over his mood swings and thought he was depressed. The Veteran stated it was difficult to share his deepest feeling with anyone. His responses to testing were indicative of depression. The Veteran reported that friends had urged him to seek professional help. The Veteran noted having symptoms of pessimism and gloom. He also had difficulty feeling motivated. He further reported having chronic headaches which would last up to 30 minutes at a time. The Veteran stated that he had had trouble sleeping for the past five years and found it difficult to fall asleep. The Veteran noted having a good relationship with his mother and father and a positive relationship with all four siblings. He was single with no significant other. The Veteran was not receiving any treatment for his condition. He stated that he intended to earn his B.A. degree. The Veteran reported that he liked to be alone and that he felt uncomfortable around strangers, in crowded places, or in heavy traffic. He worked as a waiter at the Olive Garden. His relationship with his supervisor was good and it was fair with his co-workers. While performing this job he had not lost any time from work. Mental status examination revealed orientation was within normal limits and hygiene was appropriate. Behavior was appropriate and the Veteran maintained good eye contact. Affect and mood showed a flattened affect. The Veteran's affect was anhedonic, along with depressive tones to combat experiences. Communication was within normal limits but the Veteran showed impaired attention and/or focus. He admitted to having difficulty concentrating or finding meaning in many of his studies required for college. Panic attacks were absent and no suspiciousness was present. There was also no delusional history and no delusions at the time of the examination. Thought processes were appropriate and the Veteran was able to read and understand directions. He did not have slowness of thought and he was not confused. Suicidal and homicidal thought was absent. The examiner rendered a diagnosis of PTSD with loss of concentration and assigned a GAF score of 75. The examiner indicated that the Veteran was capable of managing his funds and did not have problems performing his activities of daily living from a mental standpoint. He was able to maintain and establish effective work/school/social relationships. He was also able to maintain effective family role functioning. The Veteran had no difficulty understanding commands and was not a danger to himself or others. At the time of a December 2009 VA examination, the Veteran reported that his PTSD had worsened. He noted that his longest relationship with a girl has been 5 months. He kept to himself and did not date. He also reported isolating a great deal. He tried reading but was easily bored. He was checking with college officials and struggling with restarting college. He had had average grades. The Veteran did finish community college. He was thinking of transferring to a four year college. The Veteran worked construction with his brother in the past but there was little work available. If work became available he would get a full-time job in construction. He noted that even though he had some difficulty concentrating he thought he could complete a college level curriculum. Mental status examination revealed he was cooperative and a reliable historian. His speech was clear and he was casually dressed and well groomed. Eye contact and hygiene were good. Thought processes were logical, linear, goal directed, and of normal speed. He was oriented in all spheres. Long and short-term memory were intact. Judgment was intact. There were no signs of delusions or hallucinations or other signs of psychosis. He was in no psychiatric distress. The Veteran complained of intermittent bouts of anxiety. He had anxiety while driving. The Veteran reported having some verbal outbursts but isolated more which better controlled his anger. He had mild depressive moods three days a month, lasting about 1/2 day. The depressive mood resulted in lack of motivation. He had had suicidal thoughts in the past but none at the time of the examination. He was not a danger to himself or others. There were no obsessive-compulsive symptoms. He continued to have sleep problems with nightmares three to four times per week. The Veteran described his future as uncertain. He expressed concerns about a job, schooling, and lack of socialization and relationships. He was not dating as his girlfriend had left him. He continued to have daily intrusive thoughts and intermittent flashbacks precipitated by loud noises. These problems resulted in minor difficulties with concentration. He described avoidance phenomena and emotional numbing and had a strong startle response and feelings of hypervigilance. The Veteran was competent to manage his funds. The examiner rendered a diagnosis of mild PTSD and assigned a GAF score of 70-75. The examiner noted that the Veteran's mild TBI and mild PTSD symptoms were overlapping. The Veteran used a day minder for his lack of concentration. His mild depressive moods caused some difficulty in motivation and anger outbursts. Although unemployed, the Veteran stated that he could work full-time. He also noted that he thought he could succeed in college. The examiner stated that the Veteran's prognosis was guarded. The Veteran was afforded an additional VA examination in July 2011. The Veteran reported having symptoms of depressed and anxious moods and feelings of hopelessness much of the time. He stated that his symptoms were severe. He noted that they had periods of remission. The length of remissions were hours. The Veteran enjoyed fishing by himself. He had a dog that was helping his mood. The Veteran reported fair adjustment during remission. He noted that his symptoms caused him to frequently isolate. The Veteran did not have a history of violence or suicide attempts. The Veteran reported being seen at the VetCenter for counseling. He had not received psychotherapy in the past year. The Veteran reported having a significant relationship with a lady he had known since high school. He noted isolating most of the time and routinely avoided social interaction. He found it difficult dealing with people and hard to imagine working for anyone full-time. These changes had occurred in the past year. He worked construction for six months but could not keep up with the work schedule or the stress of dealing with people. He stated that it was his belief that his unemployment was due to the effects of his mental condition because he had trouble working around people. Mental status examination revealed orientation was within normal limits. Appearance and hygiene were not appropriate and showed signs of neglect. His appearance was disshelved and there was minimal focus on hygiene. He had poor eye contact during the examination. Affect and mood showed mood swings, anxiety, and depressed mood. The Veteran had emotional numbness or detachment from others, avoidance of social interaction, and intrusive recollections of horrifying combat events. Communication and speech were within normal limits. Concentration was also within normal limits. Panic attacks were absent and there was no suspiciousness present. There were also no delusions or hallucinations. Obsessive compulsive behavior was absent. Thought process was appropriate and the Veteran was able to understand directions. He did not have slowness of thought and did not appear to be confused. Judgment was not impaired and abstract thinking was normal. Memory was within normal limits. Suicidal and homicidal ideation were absent. Symptoms of PTSD included emotional detachment or numbness, avoidance of social interaction, intrusive recollections, and feelings of hopelessness. The examiner rendered Axis I diagnoses of PTSD and a cognitive disorder. He stated that the diagnoses were not related. He indicated that the PTSD symptoms included emotional numbness, intrusive recollections of horrifying events, efforts to avoid thinking about disturbing events, and feelings of depression and hopelessness. Cognitive disorder symptoms included chronic and debilitating headaches, sleep impairment, irritability, angry outbursts, verbal aggression, and inflexibility. The examiner assigned a GAF score of 55-60. The examiner indicated that the Veteran remained emotionally numb and isolated himself often. The PTSD effects on the Veteran's employment and overall quality of life included his having been unable to find employment that he could hope to tolerate in terms of having to interact with others routinely. He was capable of managing payments in his own best interest. The examiner stated that the Veteran's psychiatric impairment caused occupational and social impairment with decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. The examiner noted that the statement was supported by depressed mood, anxiety, chronic sleep impairment, feeling the need to isolate frequently, and avoiding most social interaction opportunities. The Veteran was noted to have difficulty maintaining effective family functioning and seldom communicated with his family. His significant other tried to accept the Veteran's isolation tendencies. The Veteran was encouraged to seek psychiatric follow-up treatment. He was not a danger to himself or others. The prognosis was guarded to fair. His PTSD symptoms were noted to have worsened significantly in the past few years. After a review of all the evidence, lay and medical, the Board finds that the criteria for a disability evaluation in excess of 50 percent were not met or nearly approximated prior to July 25, 2011. For the period prior to July 25, 2011, the Board finds that the Veteran's PTSD symptoms were not shown to be more than moderate in degree and only moderately impacted social and occupational functioning. The Veteran's PTSD symptoms and the severity of his symptoms did not more nearly approximate the criteria for a 70 percent disability (occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood) prior to this time. 38 C.F.R. §§ 4.3, 4.7. As mentioned above, for a rating in excess of 50 percent, the PTSD would have to manifest deficiencies in most occupational and social areas, such as work, school family relations, judgment, thinking or mood, due to such symptoms as, for example only, suicidal ideations; 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 settings); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. Prior to July 25, 2011, the Veteran was not shown to have suicidal plans or intentions. There were no findings or assertions of suicidal or homicidal plans or intentions. There were no obsessional rituals found which interfered with routine activities. Speech was not found to be intermittently illogical, obscure, or irrelevant at any time during this period, including on the VA examinations. There were also no panic episodes. While depression and anxiety were noted, they were not found to be near-continuous. Although the Veteran indicated that he was easily irritated and impatient, there were no periods of violence. He was also found to be alert and oriented to time, place, and person during this time frame. There were also no findings of neglect of personal appearance and hygiene prior to July 25, 2011. As to relationships, while the Veteran reported that he tended to isolate and preferred to be alone, he still had contact with his family. Furthermore, the GAF scores of 70-75 assigned at the time of the December 2008 and December 2009 VA examinations are indicative of mild and certainly no more than moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general rating formula for mental disorders is 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; however, the Court further indicated that without those examples, differentiating between rating evaluations would be extremely ambiguous. Id. at 442. With this in mind, the evidence shows that the Veteran's overall PTSD picture prior to July 25, 2011, was adequately contemplated by the existing 50 percent rating. The Veteran did suffer from sleep problems, but this is specifically listed under the criteria for a 30 percent rating, a lower rating than the current 50 percent evaluation. Disturbance of motivation and mood, and difficulty in establishing and maintaining relationships are specifically contemplated in the 50 percent rating criteria. The same is true with the Veteran's depression and anxiety, which are symptoms contemplated under the 30 percent PTSD disability rating. A 50 percent PTSD disability rating also considers "disturbances of motivation and mood" which would include the Veteran's reported depression and anxiety symptoms. Despite the Veteran's contention that his PTSD symptoms warranted an evaluation in excess of 50 percent, the Board finds that the evidence of record does not support this contention prior to July 25, 2011. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for an increased rating in excess of 50 percent for PTSD prior to July 25, 2011, and the appeal for a higher rating for this period is not warranted. As the preponderance of the evidence is against a higher rating for this period, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. PTSD Evaluation from July 25, 2011 The Board finds that, with the resolution of reasonable doubt in the Veteran's favor, the criteria for a 70 percent disability evaluation for PTSD have been more nearly approximated for the period from July 25, 2011 at this time. The Board finds that for this period the Veteran's PTSD has caused occupational and social impairment with deficiencies in most areas including difficulties in the work environment, mood problems, impaired impulse control, unprovoked irritability, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective relationships, near continuous depression, lack of energy/motivation, and intrusive thoughts. For the period from July 25, 2011, the Veteran has experienced difficulty obtaining and maintaining employment as a result of his PTSD, and difficulty maintaining relationships with all others but his significant other. The Veteran has also been shown to have had an increase in impaired impulse control and unprovoked irritability, as well as daily episodes of increased depression for this period. The Veteran has also been found to have clinically significant distress or impairment in social, occupational, and other important areas of functioning, to include withdrawing from others and only interacting with his significant other, including at the time of his most recent VA examination. The Veteran has reported and has been found to prefer social isolation. There have also been notations of the Veteran having neglect for personal appearance and hygiene since this time. While this may not continue into the future, at this time, the Veteran meets the 70% standard based on all the evidence. Beyond the above, the assigned GAF score of 55 demonstrates a significant worsening in the Veteran's PTSD symptoms. For the above reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that, for the time period from July 25, 2011, the Veteran's PTSD symptoms more nearly approximated the requirements for a schedular rating of 70 percent under Diagnostic Code 9411. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board concludes that the Veteran's disability picture does not more nearly approximate the criteria for a 100 percent rating criteria under DC 9411 for this period. 38 C.F.R. § 4.130 . The lay and medical evidence does not show that the Veteran has total occupational and social impairment, including 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; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Veteran's own statements would not support such a finding. When rating only the PTSD, the Board finds that the symptomatology and social and industrial impairment due to symptoms associated with the Veteran's PTSD more nearly approximates the 70 percent disability rating criteria at this time, which specifically recognizes and rates based on occupational and social impairment, with deficiencies in most areas including work and difficulty in adapting to stressful circumstances, including work or a work like setting. See Mauerhan at 441-443 (if the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned). Headaches The Veteran maintains that the symptomatology associated with his headache disorder warrants an evaluation in excess of 30 percent throughout the appeal period. Under Diagnostic Code (DC) 8100, a 30 percent rating is assigned for migraine headaches when a veteran has characteristic prostrating attacks averaging once per month over the last several months. A 50 percent rating is assigned for migraine headaches when a Veteran has very frequent, completely prostrating headaches with prolonged attacks that are productive of severe economic inadaptability. 38 C.F.R. § 4.124a. In this regard, it is important for the Veteran to understand that the Board may not use a problem associated with PTSD to increase the evaluation of this problem. In conjunction with his claim, the Veteran was afforded a VA examination in December 2008. At the time of the examination, the Veteran reported having 4-5 headaches per week. The Veteran stated that the headaches were pulsating. When they occurred, he was able to take care of household chores but not able to go to work. The headaches would last for up to six hours. The examiner rendered a diagnosis of headaches. At the time of an October 2009 VA examination, the Veteran reported that his headaches started in the back of his head and radiated to the forehead and were associated with light sensitivity and nausea, but no vomiting. When the headaches occurred he had to stay in bed and not do anything. He experienced headaches on average three times per month which would last for six hours. Physical examination of the cranial nerves revealed normal findings. The examiner indicated that the diagnosis was changed to traumatic brain injury with migraine headache residual. The effect of the condition on the Veteran's usual occupation was trouble functioning with migraine headaches. He was also noted to have trouble with daily activity when having a migraine headache. At the time of a July 2011 VA examination, the Veteran reported having headaches which were bi-frontal with posterior radiation with light and sound sensitivity and minimal nausea. When the headaches occurred, the Veteran was able to take care of household chores but not able to go to work. The level of pain was 9 out of 10. The Veteran reported experiencing headaches three times per week which would last up to four hours. Neurological examination revealed that the cranial nerves were intact. The examiner rendered a diagnosis of migraine headaches. The Board finds that a disability evaluation in excess of 30 percent for headaches have not been met for any period. The evidence does not demonstrate that the Veteran's headaches have caused severe economic inadaptability at any time. The Board notes that the record contains statements from the Veteran that he had had to take several days off from work as a result of headaches when he worked but the headaches have been no more than three times per week. There have been no findings or evidence demonstrating severe economic inadaptability at any time. While the headaches interfere with employment, the evidence of record does not demonstrate severe economic inadaptability. As the preponderance of the evidence is against an evaluation in excess of 30 percent for any period, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the schedular rating criteria contemplate the impairments and symptoms associated with the Veteran's PTSD. The symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested difficulty sleeping, depression, unprovoked irritability, anxiety, and difficulty with maintaining work and social relationships. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. There have been no findings by any VA examiner that his PTSD alone causes total occupational impairment. Without problems associated with these disorders there would be no bases for the current findings, let alone higher evaluations. As it relates to the headache disorder, the Board finds that the symptomatology and impairment caused by the Veteran's headache disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The rating assigned under DC 8100 is based on the average impairment of earning capacity resulting from headaches involving prostrating attacks. The rating criteria specifically contemplate the frequency and severity of the headaches, including whether the headaches are prostrating, and includes consideration of economic inadaptability. The record contains no indication that the Veteran's headache disability causes him greater difficulty than that contemplated by the 30 percent rating assigned in this decision. While the Veteran is having difficulty staying employed for long periods, the record does not indicate that individual unemployability is being raised by the record at this time. Because the schedular rating criteria are adequate to rate the Veteran's disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R.§ 3.321(b)(1). Duty to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Veteran was notified of the provisions of the VCAA by the RO in correspondence dated in November 2008. This letter notified the Veteran of VA's responsibilities in obtaining information to assist him in completing his claim, identified the Veteran's duties in obtaining information and evidence to substantiate his claim, and provided other pertinent information regarding VCAA. With respect to the Dingess requirements, in November 2008, the RO provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. With that notice, the RO effectively satisfied the remaining notice requirements with respect to the issues on appeal. Next, VA has a duty to assist a veteran in the development of his claim. 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. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). All necessary treatment records have been obtained and the Veteran has not indicated that there remain any outstanding treatment records. The Veteran was provided with VA examinations in December 2008, October 2009, December 2009, and July 2011. The Board finds the above VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The VA examiners personally interviewed and examined the Veteran, including taking a history from the Veteran, and provided the information necessary to evaluate the Veteran's disability under the applicable rating criteria. The Board therefore finds that no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A disability evaluation in excess of 50 percent for PTSD prior to July 25, 2011 is denied; a 70 percent disability evaluation for PTSD from July 25, 2011 is granted. A disability evaluation in excess of 30 percent for headaches due to head trauma is denied. REMAND As it relates to the claim for an increased disability evaluation for a scar of the left flank, the Board notes that the last VA examination afforded the Veteran, as it relates to the scar, was in July 2011. The Veteran's representative, in his August 2013 written argument, indicated that the Veteran contended there was numbness and pain associated with this scar. He stated that the Veteran requested an additional VA examination if the 10 percent disability evaluation could not be granted as one was warranted where the disability may have worsened. VA is obligated to afford a veteran a contemporaneous examination where there is evidence of an increase in the severity of the disability. VAOPGCPREC 11-95 (1995). The Veteran is competent to provide an opinion that his disability has worsened. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for a VA examination to determine the severity of his left flank scar (if any). The claims folder must be made available for review by the examiner. In addition to reporting on the appearance of the scar and any resulting residuals, to include any muscle damage, the examiner should comment on whether the scar is adherent to the underlying tissue and whether the scar residuals result in any neurological impairment. If neurological impairment is found to be present, the examiner should identify the nerves affected and whether the impairment is mild, moderate, or severe in nature. A rationale is requested for any opinion that is rendered. 2. To help avoid future remand, the RO must ensure the required actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, corrective action should be undertaken before the claims file is returned to the Board. See Stegall v. West, 11 Vet. App. 268 (1998). 3. After completing the above development, readjudicate the remaining claim. If the disposition remains unfavorable, furnish the Veteran and his representative with a supplemental statement of the case (SSOC), and afford the applicable opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if appropriate. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs