Citation Nr: 1423382 Decision Date: 05/22/14 Archive Date: 05/29/14 DOCKET NO. 12-06 925 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased rating for service-connected adjustment disorder, with anxious features, and posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to an initial compensable evaluation for service-connected tremors of the head and neck prior to May 3, 2004. 3. Entitlement to an evaluation in excess of 10 percent for service-connected tremors of the head and neck as of May 3, 2004. 4. Entitlement to a total rating based on unemployability due to service-connected disability (TDIU). WITNESSES AT HEARINGS ON APPEAL Appellant, appellant's spouse ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from December 1963 to September 1967, and from December 1990 to May 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Department of Veterans Affairs (VA) Regional Offices (RO). In February 2002, the RO in Pittsburgh, Pennsylvania, inter alia, granted service connection for tremors of the head and neck , and assigned an initial, noncompensable rating, effective July 17, 1998. In July 2010, the RO in Houston, Texas, granted a claim for an increased rating for service-connected adjustment disorder, with anxious features, and posttraumatic stress disorder (PTSD), to the extent that it assigned a 50 percent rating, with an effective date of September 8, 2009. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. In October 1999, the Veteran and his wife testified during a hearing before a Decision Review Officer (DRO) at the RO. In October 2012, the Veteran and his wife testified during a hearing before the undersigned Veterans Law Judge. Transcripts of the hearings are of record. The appellant had been represented in this matter by an accredited agent; however, he has revoked this representation and is currently unrepresented before the VA. 38 C.F.R. § 14.630 (2013). This was made clear at the hearing held in October 2012. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to May 3, 2004, the Veteran's service-connected tremors of the head and neck are not shown to have been productive of moderate symptoms. 2. As of May 3, 2004, the Veteran's service-connected tremors of the head and neck are not shown to have been productive of severe symptoms. 3. The Veteran's service-connected adjustment disorder, with anxious features, and PTSD, is shown to have been manifested by symptoms that include anxiety, nightmares, sleep disturbance, and irritability, but his symptoms are not shown to have resulted in severe impairment in the ability to obtain or retain employment, or in occupational and social impairment, with deficiencies in most areas. CONCLUSIONS OF LAW 1. Prior to May 3, 2004, the criteria for an initial, compensable rating for tremors of the head and neck have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.27, 4.124a, Diagnostic Code 8103 (2013). 2. As of May 3, 2004, the criteria for a rating in excess of 10 percent for tremors of the head and neck have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.27, 4.124a, Diagnostic Code 8103 (2013). 3. The criteria for a rating in excess of 50 percent for adjustment disorder, with anxious features, and PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130, Diagnostic Code 9440 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Initial Evaluation Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. A. Tremors of the Head and Back The Veteran asserts that he is entitled to an increased initial evaluation for his service-connected tremors of the head and back. During a hearing at the RO in October 1999, the Veteran testified that he had been placed on two medications for his head tremor. He stated that his tremor got worse when he was agitated or nervous. He added that his tremors were getting worse, and that he experienced continuous tremors 24 hours a day. The Veteran's wife testified that his tremors were not very noticeable when he was in a sitting position, but, that his head would start moving as he was writing, and that the tremor was really bad when he was using his hand, for example, writing, eating, or typing. She added that his medication helped a lot, but that the tremor was still visible. In an April 2001 statement, the Veteran's wife reported that, in May 1991, she noticed that the Veteran's head would shake when he typed and ate. She added that this shaking progressed and became more profound until she insisted that he see a doctor in 1995 and that, since that time, he continued to see his doctor twice a year and took several medications per day for this chronic condition. In an August 2001 statement, the Veteran reported that his head tremor was worse when distracted, and that his head shook when his dentist was working on his mouth and when he got his haircut. He described his symptoms as very nerve racking and added that they made his condition worse. In his March 2002 notice of disagreement, the Veteran reported that he had recently had minor eye surgery which was made much more difficult because of his tremor. In a statement, dated in September 2007, the Veteran asserted that he should be awarded a 30 percent rating. He stated that, "My tremor is better on some times and worse on others. There are many factors involved in my tremors caused by military service." He essentially argued that he had a loss of balance due to his tremors. During a hearing, held in October 2012, the Veteran testified that he has such symptoms as difficulty concentrating, and that he had recently left his home for day until "I came back to my senses." He asserted that he had retired from his job in 2002, due to anxiety and his tremors. He testified that he took Lexapro, Xanax, and a medication for sleeping, as he only slept about four hours per night. He stated that he had few friends, and that he tended to agitate people. He further stated that he saw a VA psychiatrist twice a year, and that he had seen a private therapist about once a week for about seven years. With regard to his tremors, the Veteran testified that he had head tremors that were aggravated by typing on his computer, and that his tremors had spread to his upper extremities and that they affect his handwriting. The Veteran testified that his tremors "can happen early in the morning," that his head "may shake for hours on end," and that his symptoms were helped by use of Xanax, and sometimes lessened after taking a nap. He stated that his symptoms got worse as the day progressed, that his hands shook "all the time," and that he had had to quit golfing. He stated that he could drive, but that he could not do such mechanical things as use a screwdriver, and that he could not write. The VLJ observed that the Veteran was not shaking during his testimony. The Veteran's spouse testified that the Veteran often screams at other drivers, has a high anxiety level, has a diminished relationship with his children, and cannot focus on one thing for more than a few minutes. In February 2002, the RO inter alia, granted service connection for tremors of the head and neck, and assigned an initial, noncompensable rating, with an effective date for service connection of July 17, 1998. The Veteran appealed the issue of entitlement to an initial compensable evaluation. In November 2003, August 2005, the Board remanded the claim for a higher initial evaluation to the RO for further development. In February 2006, the Appeals Management Center (AMC) granted the claim, to the extent that it assigned a 10 percent rating for tremors of the head and neck, effective May 3, 2004. As this did not constitute a full grant of the benefits sought, the increased evaluation issue remained in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). In July 2006, the Board again remanded the Veteran's claim to the RO, via the AMC, for further action, to include additional development of the evidence. In May 2008, the Board (another Veterans Law Judge) denied an initial, compensable rating for tremors of the head and neck, prior to May 3, 2004, and remanded to the RO, via the AMC, the matter of entitlement to a rating in excess of 10 percent for tremors of the head and neck since May 3, 2004. In February 2010, the Board (another Veterans Law Judge) denied the claim for a rating in excess of 10 percent from May 3, 2004. The Veteran appealed the Board's May 2008 decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2010 memorandum decision, the Court vacated the Board's decision and remanded the claim for an initial, compensable rating for tremors of the head and neck, prior to May 3, 2004, to the Board for further proceedings consistent with the memorandum decision. The Veteran also appealed the February 2010 Board decision denying a rating in excess of 10 percent for tremors of the head and neck, as of May 3, 2004, to the Court. In October 2010, the Court granted a joint motion for remand filed by representatives for parties, vacating the Board's decision, and remanding the claim to the Board for further proceedings consistent with the joint motion. In May 2011, the Board remanded the claims for additional development. The Veteran has disagreed with the initial rating assigned following the grant of service connection. Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). With regard to the history of the disability in issue, private treatment reports dated between 1995 and July 1998, show treatment for complaints of a head tremor. His physical examinations were normal. He was eventually started on Inderal, with which he was somewhat better, and noted to have mild rigidity in his wrists. He was noted to report that his symptoms worsened with stress, but his condition was characterized as "stable" in 1996. A December 1997 report noted that the Veteran reported that his tremor was worse under stress, but that it was stable, and that use of Inderal "does help a lot." The report notes that there was no tremor visible on examination. See 38 C.F.R. § 4.1 (2013). The RO has evaluated the Veteran's tremors under 38 C.F.R. § 4.124a, Diagnostic Codes 8099-8103. These diagnostic codes indicate that the tremors of the head and neck were being evaluated, by analogy, to a convulsive tic. See 38 C.F.R. §§ 4.20 and 4.27 (2013). Under Diagnostic Code 8103, a convulsive tic warrants a noncompensable rating when mild, a 10 percent rating when moderate, and a 30 percent rating when severe. A note indicates that the rating depends on frequency, severity, and muscle groups involved. 38 C.F.R. § 4.124a, Diagnostic Code 8103. The terms "mild," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The Board notes that in the Court's May 2010 decision, it stated that it declined to address the Veteran's argument that, "the Board had failed to account for the fact that he takes multiple medications for his condition and that he had 'break-through' symptoms despite medication." The Court explained that: "The appellant has not provided the Court with any authority that the Board must attempt to consider the severity of his condition without medication." The Board incorporates this reasoning into its decision herein, and will not attempt to evaluate the severity of the Veteran's disability without use of medication. In this regard, it is important for the Veteran to understand that any disability is normally evaluated with consideration of medication to treat the problem. If there are side-effects to this medication, the Board would consider this fact. 1. Prior to May 3, 2004 The relevant medical evidence is summarized as follows: Records of private treatment from November 1995 to April 1998 show treatment for a head tremor. A VA general medical examination report, dated in October 1998, shows that the Veteran reported that he was told by his wife and daughter in 1995, or earlier, that he had a tremor of his head. The Veteran stated that he went to see a neurologist and was started on Inderal LA. He reported that he got an almost immediate response and was markedly improved, although he still had a slight hand tremor and slight tremor of his head. The Veteran added that, in addition to Inderal LA, he had been treated with Xanax. On examination, neurological findings were normal. The examiner noted that musculoskeletal examination was within normal limits except for the slight tremor of both hands, and, "occasionally it is visible to see a tremor of his head, which is a fine tremor but it comes on intermittently." The relevant diagnosis was intentional tremor. A VA neurological examination report, dated in October 1998, shows that the Veteran complained of "head vibration" which was positional, especially on reclining. The examiner noted that this tremor was addressed by the Veteran's private physician, "Dr. B," and that a diagnosis of central tremor was made in November 1995. The examiner added that, apparently, some neck tremor was seen, right greater than left, but that the Veteran described himself as markedly improved since November 1995. On examination, there was no tremor of the head or neck. The examiner concluded that examination was completely within normal limits, and that, while a neck tremor, compatible with the diagnosis of a central tremor, was present in 1995, it was completely eliminated by treatment. The examiner noted that the Veteran continued in Dr. B's care. In a March 1999 letter, Dr. B stated that she had followed the Veteran for a tremor since November 1995. She reported that the Veteran was placed on beta blockers and ultimately Inderal LA, which did improve his tremor. She added that he was currently on Xanax and Inderal LA. Dr. B indicated that, on examination, the Veteran had some mild intermittent head tremor on medication. She added that there was no postural component to his tremor, and there was no resting tremor. She concluded by stating that the Veteran's tremor was under control with medication, but that it would require continued neurologic evaluation and medication. In a December 1999 letter, Dr. B stated that the Veteran had been on a variety of medications, and was currently on Inderal LA and Xanax. She added that, on examination, he had a slow, side to side head tremor with writing, walking, and fine motor movements, and that the tremor increased with distraction. He also had a trace postural tremor and a trace intention tremor. In an August 2000 letter, Dr. B reported that she had last examined the Veteran in June 2000, at which time he had a mild intermittent intention tremor of his head. She stated that the Veteran was suffering from an intention tremor. A September 2000 report from Vista Behavioral Health Associates notes use of propranolol-LA daily for his tremor, "and indicates that this has helped substantially." A VA neurological examination report, dated in August 2001, shows that the Veteran reported that he was currently under the care of Dr. B, and that he was taking Inderal LA, Xanax, and citalopram. A neurological examination was unremarkable, without evidence of abnormality, except for a slight, intermittent, brief tremulousness of the head, observed on two occasions, and possibly a slight voice tremor. The examiner noted that the Veteran's neck tremor stopped when his cranium was touched, and that there was no cog wheeling when the neck was passively ranged. The diagnosis was chronic, persistent head-neck tremor, with an excellent response to Dr. B's medical management. A VA genitourinary examination report, dated in November 2002, shows that the Veteran reported that his head tremors were treated with Inderal, however, on examination, the examiner could detect no gross tremors about the neck or head. A VA mental disorders examination, dated in November 2002, shows that the Veteran reported that he was taking Xanax to manage essential head tremor symptoms, on an as-needed basis, approximately one time per month. The Veteran reported that he had retired after 26 years as a liquor control board agent because "work was annoying me." He stated that he had been worried about the effects of his head tremor, as well as side effects from medications. He denied having any disciplinary actions against him during his employment tenure and denied receiving any negative work evaluations. He reported that he currently performed part-time employment at a non-profit correctional facility as a technician. He stated he had held this job for 11/2 years, and that he worked eight hours per week. On examination, there was no overt psychomotor agitation Records from Allegheny Neurological Associates, dated between July 1998 and May 2004, include findings of, and treatment for, a head tremor. A December 1998 report notes a min[imal] head tremor/trace kinetic tremor, with no postural tremor. The report notes "tremor = same." A November 1999 report notes a side-to-side head tremor with fine motor movement, such as writing, and with walking, and a trace postural tremor, and mold mirror movement in the hands. The report notes, "tremor about the same." An October 2000 report shows that the Veteran reported that his head tremor was worsened with intake of caffeine and chocolate. See also June 2001 report (same). The report notes that his head tremor had improved. Continued use of Inderal and Xanax was indicated. In January 2001 the Veteran reported that his tremor was "OK" for now, on medication, and Dr. B diagnosed a mild postural and head tremor. A June 2001 report notes that the Veteran's tremors were "about the same." There was a trace head tremor, and no postural tremor. A June 2002 report notes " a little hand tremor," and that the Veteran was typing more on his computer. There was also a trace head tremor. The Board finds that a compensable rating for the period prior to May 3, 2004 is not warranted. The Veteran's tremors are primarily manifested in the areas of his head and hands, with a few findings of a postural tremor. The medical evidence shows that both VA and private examiners have repeatedly and consistently described the Veteran's tremors of the head and neck as "trace," "slight" and "mild." They were also described as minimal, providing highly probative evidence against this claim. The Veteran himself described his head tremor as "slight" upon VA examination in October 1998, and the examiner described the Veteran's head tremor as a fine tremor, providing factual evidence against his own claim. The Veteran's private physician, Dr. B, described his head tremor as "mild" in her March 1999, August 2000, and January 2001 letters. The August 2001 VA examination report similarly notes a slight, intermittent, tremulousness of the head. There are no relevant findings during the last one year and five months of the time period in issue, i.e., that is dated between November 2002 and May 2004. There are two reports indicating that the Veteran continued to golf during the time period in issue. See August 2002 report from G.J.K, M.D. (noting complaints of groin pain since "swinging golf clubs a couple of weeks ago"); May 2004 report (noting that the Veteran reported that he had "played 18 holes golf today (without) problem"). The Board therefore finds that the Veteran's symptoms are not of such severity to approximate, or more nearly approximate, the criteria for a compensable evaluation under DC 8103 prior to May 3, 2004. See 38 C.F.R. § 4.7. In reaching this decision, the Board has considered that the May 2010 Court decision, which shows that the Court stated: It does not appear that the Board adequately considered the 'frequency' in which the appellant experienced the tremors." The Court noted that the Board had acknowledged the Veteran's testimony that he had continuous tremors 24 hours per day, "but discounted that lay testimony on the basis that the medical reports described the tremors as 'slight and mild.'" The Court stated that the Board was "conflating evidence supporting the 'frequency' of the tremors, with the medical professional's description of the 'severity' of each tremor." The Court therefore determined that the Board's statement of reasons and basis for its decision was inadequate. In this regard, it is important to note that, at this time, it is not only the medical evidence of record that indicates the mild nature of the Veteran's disability, but the Veteran's own prior statements, as cited above, during his medical treatment. As noted above, the Veteran himself described his head tremor as "slight" upon VA examination in October 1998, and the examiner described the Veteran's head tremor as a fine tremor, providing factual evidence against his own claim. Further, it is not only VA medical providers that have indicated this problem to be "mild", but private medical providers as well: As note above: The Veteran's private physician, Dr. B, described his head tremor as "mild" in her March 1999, August 2000, and January 2001 letters. A note to Diagnostic Code 8103 indicates that the rating depends on frequency, severity, and muscle groups involved. 38 C.F.R. § 4.124a, Diagnostic Code 8103. These criteria are conjunctive, not disjunctive; therefore all three aspects of the symptoms must be considered. See Melson v. Derwinski, 1 Vet. App. 334 (1991). However, the terms "mild," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The Board finds that when the frequency of the symptoms, as well as the severity of the symptoms, and the muscle groups involved, are considered together, that the criteria for an initial compensable evaluation have not been met. DC 8103; Melson. Both VA and private examiners have repeatedly characterized the Veteran's tremors at "intermittent." See e.g., Dr. B's letters, dated in March 1999 and August 2000; VA examination reports, dated in October 1998 (general medical) and August 2001. The October 1998 general medical VA examination report also characterized the Veteran's head tremors as only "occasionally" visible. Furthermore, in some reports, it was specifically found that a head tremor was not present. See VA examination reports, dated in October 1998 (neurological), and November 2002 (genitourinary). Finally, notwithstanding the diagnosis in an August 2001 VA neurological examination report, which notes "chronic and persistent head-neck tremor," this diagnosis also noted that there was "an excellent response to Dr. B's medical management." The examination report shows that a spiral drawing was performed without any evidence of tremor, and that the Veteran's tremors were characterized as both "intermittent" and "brief." See Lee v. Brown, 10 Vet. App. 336, 338 (1997) (an etiological opinion should be viewed in its full context, and not characterized solely by the medical professional's choice of words). In summary, when the evidence as to the frequency, severity, and the muscle groups involved, are considered together, that the criteria for an initial compensable evaluation have not been met. DC 8103. Simply stated, we have Veteran's testimony that he had continuous tremors 24 hours per day versus three important sources that totally refute this testimony: (1) the private doctors reports, as cited above; (2) the VA reports, as cited above; and, most importantly, (3) the Veteran own prior statements to his own health care providers, which, overall, are simply not consistent with his testimony. The Board has fully considered the frequency in which the appellant experienced the tremors, and finds as follows: Based on the foregoing, the Board finds that the record presents no basis for assignment of an initial compensable schedular rating for tremors of the head and neck from the July 17, 1998, the effective date of the grant of service connection, through May 2, 2004. 2. As of May 3, 2004 The relevant medical evidence is summarized as follows: a report from J.J., M.D., dated May 3, 2004, shows that the Veteran reported that his head tremors were aggravated by caffeine, chocolate, stress, fatigue, and not getting enough sleep. He reported that he had cramping and shaking after using a chainsaw, hedge clippers, and shovels, and, "He feels this may be due to gripping too hard." The report further notes, "His hand tremor sometimes interferes when he is writing a check if he does not concentrate," and that he sometimes preferred to type important things rather than writing. He was noted to be taking Inderal-LR 80 mg. in the morning with "excellent response." He was also noted to be taking Xanax 0.5 mg. three times a day (addendum). On examination, he was able to draw intersecting pentagons. There was a 1+ tremor on the right and a +0.5 tremor in the left hand. A VA psychiatric examination report, dated in October 2004, shows that the examiner noted that at the time of a November 2002 VA examination, the Veteran reported that he was able to maintain regular and steady employment with no disciplinary actions or negative performance evaluations, with no disruption in his ability to function adequately as a result of his psychiatric diagnosis. A letter from C.N.B., M.D., dated in October 2005, states that the Veteran has a tremor of his head and hands, and that they should be rated at the "severe" level because he entered the service fit for duty, he was exposed to neuro-toxic chemicals during the Gulf War such as PSB (pyridostigmine bromine), his tremor began shortly after service, and PSB is a known neuro-toxic agent and can caused tremor/twitching. A VA neurological examination report, dated in November 2005, shows that the Veteran reported a history of intermittent head tremor following service, which gradually progressed over time, especially around 1994 or 1995. Use of Inderal-LA had resulted in a "significant improvement" in his head tremor. He had also been started on Xanax, since stress was considered to be a significant contributing factor to his tremor. The Veteran reported a history of intermittent hand tremors beginning "several years ago," that were gradually worsening. He reported his symptoms were exacerbated by such things as stress, anxiety, hunger, lack of sleep, and tasks requiring prolonged concentration, such as fine motor tasks. He also complained of deterioration in his handwriting, and social embarrassment due to his tremors. He was noted to able to perform all activities of daily living independently. He asserted that his tremor was the primary cause of his retirement. On examination, tone and bulk were normal and symmetric, bilaterally. No cog wheeling was noted. Strength was 5/5 in the bilateral upper extremities. Deep tendon reflexes were 2+ and symmetric. There were no relevant sensory deficits. There was a postural tremor in the upper extremities, 8-10 hertz, small amplitude, 1+ posturally and 2+ kinetic component on the right and 2 on the left. The impression was action/postural tremor affecting head and bilateral upper extremities, moderate disability. A report from a private health care provider, L.K.K., dated in June 2007, notes that the Veteran had recently been diagnosed with diabetes mellitus, and that he exercises daily. A VA neurological examination report, dated in July 2009, shows that the Veteran was noted to have a history of improvement in his tremors following use of Inderal-LA and Xanax, and a history of an intermittent hand tremor. His tremors were noted to be aggravated by such things as stress, anxiety, fine motor tasks, and lack of sleep. A change in his medication regime was made in February 2008 in order to avoid complications of a recently-diagnosed pulmonary condition, specifically, he was taken off of Inderal. However, he maintained satisfactory control of his tremors and no substitutions were made. He complained that his tremor re-emerged after fine motor tasks, or other aggravating factors, but that he remained able to perform all activities of daily living independently, with some adaptive strategies. He complained of deteriorating handwriting, which was illegible at times. The impression was action tremor unchanged appendicular component since his last evaluation in November 2005. A VA neurological examination report, dated in June 2011, shows that the examiner indicated that the Veteran's claims file had been reviewed. The Veteran complained of a worsening head tremor, which now involved his arms, with use of Xanax, 0.25 mg. twice per day. He attributed his early retirement in 2002 partly due to embarrassment at his tremors, and said that he had worked in a law firm between 2002 and 2003, but that he had quit due to psychiatric issues. His course since onset in 1995 was noted to be "intermittent with remissions." There was fair response to Xanax. On examination, there were fine tremors of the hands which "is postural more manifested with hands extended." There were no resting tremors. The Veteran reported that Xanax adequately controlled his symptoms. A CT (computerized tomography) scan of the head in September 2005 was noted to have been unremarkable. The diagnosis was essential tremors stable with anxiety-related exacerbations. There were associated hand and arm tremors, and worsening head tremor, with no effects on the usual occupation and resulting in work problems. There was imbalance, but no gait abnormality. There was difficulty with hair cutting such that the Veteran had to use the same barber. When tremors worsened with anxiety or non-taking of Xanax, there were effects on his writing, eating, shaving and social embarrassment, per Veteran's report. The report notes stable manifestations exacerbating with anxiety, with no objective worsening noted on neurological examinations. Inderal has been discontinued and his symptoms were controlled with Xanax. The severity of the Veteran's symptoms may be described as mild, and the frequency has remained unchanged based on review of his medical records. There was only evidence of mild postural tremor at this time. Writing and drawing remains unimpaired. Essential tremors involving the head and arms are well-controlled on medications. The examiner stated that the Veteran's examination remains unchanged since 2005. Finally, VA progress notes show that the Veteran was repeatedly noted to have normal bulk, tone and strength, with no relevant sensory deficit. See e.g., VA progress notes, dated in April and September of 2005, June 2010, January 2011; see also May 3, 2004 report from Dr. J.J. (same); July and December of 2009 and June 2011 VA neurological examination reports (same). He was also determined to be fully functional in his ADLs (activities of daily living). See e.g., VA progress notes, dated in April and September of 2005; February 2006; May and December of 2009, January 2011. With regard to other specific findings, in April, August and September of 2005, the Veteran was noted to play golf. In addition, an April 2005, report shows that the Veteran reported a history of intermittent head tremors, that Inderal-LA had dramatically improved his head tremors, and that he was "doing well." He reported that his hand tremors occasionally re-emerged after strenuous physical activity or emotional distress, but that they were generally short-lived. He reported some deterioration in his handwriting, but that he writes legibly. He was noted to be fully functional in his ADLs (activities of daily living). The impression was essential tremor with predominant head tremor, and mild intermittent head tremor, well-controlled on the current regimen. A September 2005 report shows that the Veteran reported satisfactory control of his head tremor, although his hand tremors were "slightly worse." On examination, there was no head tremor, or rest or postural tremor. There was mild (1+) target approaching-tremor bilaterally, slightly worse on the right. The impression was essential tremor with predominant head tremor, and mild intermittent hand tremor, controlled on the current medication. In February 2006, the Veteran reported satisfactory control of his tremors with his medication. On examination, there was no head tremor or rest or postural tremor. There was mild (1+) bilateral tremor in the extremities. The impression was essential tremor with predominant head tremor, well-controlled on the current regimen. An April 2006 report characterizes the Veteran's hand tremors as intermittent. In June 2006, the Veteran reported that he was stable, and doing well. On examination, he had normal psychomotor activity. An August 2008 report notes that there were no abnormal involuntary movements, tremors or tics. In May 2009, the Veteran reported that he was doing well with respect to his tremors. He was noted to walk well, and to exercise regularly, superficially, weight lifting and walking. On examination, there was a minimal right tremor on target approaching, absent on the left, and no head, rest or postural tremor. There was minimal difficulty with tandem walk, otherwise normal. A January 2011 report notes that he walked well unassisted, and that he reported that his tremors were under satisfactory control. He had a daily exercise regimen, including walking two miles per day and using an elliptical trainer 40 minutes per day. The Board finds that an evaluation in excess of 10 percent as of May 3, 2004 is not warranted. By history, the Board first notes that there are multiple notations in the medical evidence to the effect that the Veteran's use of Inderal-LA in 1998 had dramatically improved his head tremors. The Veteran's tremor is primarily manifested in the areas of his head and hands, with a few findings of a postural tremor. With regard to the frequency of his tremors, the Veteran's tremors have repeatedly been described by himself, or examiners, as "intermittent." In April 2005 and July 2009, he complained that his tremors "re-emerged" after fine motor tasks, or other aggravating factors. This term indicates at least a temporary cessation of symptoms, and it is consistent with the other findings of intermittent symptoms. Importantly, there are also a number of reports which show that the Veteran did not have a head tremor when he was examined. See e.g., VA progress notes, dated in September 2005, February 2006, August 2008, May and December of 2009, June 2010, January and September of 2011. With regard to the severity of his tremors, the Veteran has repeatedly stated that his symptoms were well-managed, specifically, he has used such words and terms to describe his symptoms as "satisfactory," "under satisfactory control," "stable," and reported that he was "doing well. The evidence shows that the Veteran has been found to have hand tremors of between +0.5 and 1+ (with the 1+ findings characterized as "mild"). There is also a November 2005 finding of was a postural tremor in the upper extremities, 8-10 hertz, small amplitude, 1+ posturally and 2+ kinetic component on the right and 2 on the left. The impression was action/postural tremor affecting head and bilateral upper extremities, moderate disability. The June 2011 VA examiner concluded that the severity of the Veteran's symptoms may be described as mild, and the frequency has remain unchanged based on review of his medical records. The examiner stated that there was only evidence of mild postural tremor at this time, and that the Veteran's writing and drawing remains unimpaired, providing highly probative evidence against this claim. Essential tremors involving the head and arms were noted to be well-controlled on medications. The examiner stated that the Veteran's examination remains unchanged since 2005. Finally, the evidence shows that the Veteran was repeatedly noted to have normal bulk, tone and strength, with no relevant sensory deficit, and that he was determined to be fully functional in his activities of daily living. With regard to his ability to function, there is some fairly recent suggestion of impaired balance, however, the Veteran's gait has repeatedly been noted to be normal, with no more than minimal effects. In April, August and September of 2005, the Veteran was noted to play golf. Thereafter, he has been noted to be exercising daily, with notations of walking, weight-lifting, and use of a recumbent bicycle. The facts of the case, particularly a detailed review of the treatment records and the statements of the Veteran during treatment, repeatedly provide, overall, highly probative factual evidence against this claim. With regard to the effect on employment, the Veteran has, at times asserted that his tremors forced him to retire early. See e.g., VA examination reports, dated in November 2005 and June 2011. However, in some cases, he has attributed his retirement to both his tremors and psychiatric symptoms. While the Board has considered what the Veteran and his spouse stated at the hearing held in October 2012, the Board has also reviewed this case, which has been ongoing for many years, in great detailed, particularly the treatment records, and what the Veteran said during this treatment, which, very unfortunately, overall provide highly probative evidence against this claim. The Board finds that the best evidence in this case, including the Veteran's own prior statements (overall), does not indicate that the Veteran's tremors resulted in his retirement, or that they render him unemployable. The Board has reviewed this record in great detail to make this determination. In this regard, a November 2002 VA mental disorders examination report shows that the Veteran reported that he had retired after 26 years as a liquor control board agent because "work was annoying me." He stated that he had been worried about the effects of his head tremor, as well as side effects from medications. However, he denied having any disciplinary actions against him during his employment tenure and denied receiving any negative work evaluations. An August 2005 VA progress note shows that the Veteran reported that he was retired as of September 2002, that he "liked to work," and that he had had "no problems on the job." It further appears that the Veteran started his own consulting business following his retirement. See January 2003 report from Vista Behavioral Health Associates (VHBA) (noting, "Following his retirement in the fall, he began a consulting business and that is now keeping him busy five days a week"); April 2003 VHBA report (noting that the Veteran "has been overwhelmed by hos busy his consulting business is," and that he "had to cut back on the amount of time he devotes to it"). These reports are inconsistent with his assertions of severe tremors which impaired his ability to function at his job and/or caused him to retire. Finally, the June 2011 VA examiner specifically concluded that the Veteran's tremors had no effects on the usual occupation and resulting in work problems, providing only more evidence against this claim. Given the foregoing, the Board finds that the Veteran's symptoms are not of such severity to approximate, or more nearly approximate, the criteria for a rating in excess of 10 percent under DC 8103 as of May 3, 2004. See 38 C.F.R. § 4.7. B. Adjustment Disorder, with Anxious Features, and PTSD The Veteran asserts that he is entitled to an increased rating for his service-connected adjustment disorder, with anxious features, and PTSD. During his hearing, held in October 2012, he testified that he has anxiety, and uses medications that include Xanax and Lexapro. He stated that he slept about four hours per night, and that he had difficulty concentrating. He stated that he had difficulty with his medications provided for his sleep symptoms, and that he had fallen out of bed twice in the last year. He reported that he had retired in 2002 because of his anxiety, as well as his tremors. With regard to the history of the disability in issue, see 38 C.F.R. § 4.1, the Veteran's post-service records show treatment for psychiatric symptoms beginning in about 2000, with him primarily being afforded diagnoses of anxiety disorder. His medications included Celexa. His GAF scores ranged between 49 and 63. There is no history of hospitalization for psychiatric symptoms. A letter from C.H., LPC, dated in December 2008, states that the Veteran has been in therapy since 2004, and that, "He manages his anxiety better, but still gets highly anxious with certain triggers." His symptoms were noted to include nightmares, feeling out of control, hypervigilance, and paranoia. In January 2005, the RO granted service connection for adjustment disorder, with anxious features, evaluated as 30 percent disabling. In February 2005, the RO granted service connection for PTSD, combined the rating with PTSD with that of his adjustment disorder, and continued the 30 percent rating. In each case, there was no appeal, and the RO's decisions became final. See 38 U.S.C.A. § 7105(c) (West 2002). In September 2009, the Veteran filed a claim for an increased rating for service-connected adjustment disorder, with anxious features, and PTSD. In July 2010, the RO granted the claim, to the extent that it assigned a 50 percent rating, with an effective date of September 8, 2009. The RO has evaluated the Veteran's adjustment disorder, with anxious features, and PTSD under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9440. Under DC 9440, a 50 percent rating is warranted where the disorder is manifested by 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. Important for this case, a 70 percent rating is warranted where 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 ideations; obsessional rituals that 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. Id. The Global Assessment of Functioning (GAF) scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). GAF 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). Scores ranging from 51 to 60 reflect more 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 between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. See Quick Reference to the Diagnostic Criteria from DSM-IV at 47 (American Psychiatric Association 1994) ("QRDC DSM-IV"). Although some of the Veteran's recorded symptoms are not specifically provided for in the ratings schedule (e.g., such symptoms as nightmares), the symptoms listed at 38 C.F.R. § 4.130 are not an exclusive or exhaustive list of symptomatology which may be considered for a higher rating claim. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board notes that the Veteran has been afforded diagnoses of psychiatric disorders other than an adjustment disorder, and PTSD, to include anxiety disorder, and a depressive disorder, as well as a personality disorder. In its analysis the Board has not attempted to dissociate any psychiatric symptoms from the service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has similarly emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). It held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Id. at 4. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 2. The relevant evidence is summarized as follows: VA progress notes show that the Veteran was primarily found to have normal speech, well-organized thought and goal-directed thought processes, intact memory and judgment, and good insight. There were no delusions, hallucinations, or homicidal or suicidal ideation. See e.g., VA progress notes, dated in April and October of 2010, and November 2011. A September 2011 report notes that his depression was under good control, that there was no history of psychosis, that the Veteran denied any cognitive difficulty, and that he required a small dose of Xanax for anxiety and control of his tremor. A November 2011 VA progress note states that in April 2011, the Veteran had left home after he got into an argument with his wife, but that he later returned, and his physician changed his medication regime as a result. The Veteran stated that he is "doing fine," although he still had sleep difficulties. He was noted to be stable on Lexapro and Alprazolam, although symptomatic. A report from C.H. LPC, dated in December 2009, states that the Veteran has been in therapy since December 2008. The report states the following: the Veteran continues to make progress understanding the dynamics of his situation and controlling his panic, anger, rages, anxiety and agitation. Certain triggers still made him vulnerable to feeling out of control, very angry and agitated, anxious, and even panicked. He had nightmares sometimes. In this regard, it is important for the Veteran to understand that such problems as the ones cited above are common with a person who a 50% evaluation for PTSD. If he did not have any problems with PTSD, there would be no basis for a compensable evaluation, let alone a higher evaluation. Many of the problems he has cited as the basis for a high disability evaluation for this disability are, in actuality, the basis for the current 50% finding which requires reduced reliability and productivity. A QTC psychiatric examination report, dated in April 2010, shows that the Veteran complained of worsening symptoms in the last few years, to include nightmares, anxiousness, getting easily agitated, depression, difficulty sleeping, and a dislike of being around people/social isolation and avoidance. He was noted to be taking Lexapro, 30 mg. daily, with minimal response, and Xanax, 0.25 mg. twice daily, with good response. The report notes the following: there was no relevant history of hospitalization or emergency room treatment. Over the past year, the Veteran had received psychiatric treatment as often as twice per month, with good response. The Veteran was married, and his relationship with his wife was strained. He has not worked since 2003, after retiring as an investigator for a state liquor control board after 26 years. He complained that he retired because he couldn't handle the stress of the job and he was nervous around people. On examination, the following were within normal limits: orientation, communication, speech, concentration, and memory. Appearance and hygiene, behavior, and thought processes, were characterized as "appropriate." There was a disturbance of motivation and mood. There were no panic attacks, delusions, hallucinations, obsessive-compulsive behavior, or suicidal or homicidal ideations. There was no impairment of judgment. There were behavioral, cognitive, social, affective or somatic symptoms attributable to PTSD. The Axis I diagnoses were adjustment disorder with anxious features, and PTSD. The Axis V diagnosis was a GAF score of 53. The examiner stated, "Mentally, he does not have difficulty performing activities of daily living. He has difficulty establishing and maintain effective work, school and social relationships because of anxiety around people and difficulty getting along. He has no difficulty understanding commands. His prognosis was fair with treatment, however the ability to sustain any meaningful employment is unlikely." The Board finds that an evaluation in excess of 50 percent is not warranted. The Veteran's symptoms are not shown to be sufficiently severe to have resulted in occupational and social impairment, with deficiencies in most areas, and the Board has determined that the preponderance of the evidence shows that the Veteran's adjustment disorder, with anxious features, and PTSD more closely resembles the criteria, at best, for not more than a 50 percent rating. The findings as to the Veteran's speech, thought processes, memory, insight, and judgment, are not shown to be sufficiently severe to warrant an increased evaluation. There is no evidence (for example only) of suicidal ideations, obsessional rituals that interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, spatial disorientation, or neglect of personal appearance and hygiene. There is one instance of impaired impulse control (leaving his house in April 2011). The Veteran's ability to interact with family members and others clearly appears to be impaired. With regard to employment, the Veteran has reported that he has not worked since 2003, at which point it appears he voluntarily quit his job. The April 2010 QTC examination report shows that his orientation, communication, speech, concentration, and memory, were within normal limits, and that his appearance and hygiene, behavior, and thought processes, were characterized as "appropriate." There were no panic attacks, delusions, hallucinations, obsessive-compulsive behavior, suicidal or homicidal ideations, or impairment of judgment. The Axis V diagnosis was a GAF score of 53, and this is evidence of no more than moderate symptomatology. See QRDC DSM-IV. The examiner indicated that the Veteran does not have difficulty performing activities of daily living due to psychiatric symptoms. The examiner further concluded that the Veteran has difficulty establishing and maintaining effective work, school and social relationships, and this corresponds to no more than a 50 percent rating. See 38 C.F.R. § 4.130. Finally, the Board has considered the QTC examiner's notation that the Veteran's ability to sustain any meaningful employment is unlikely. However, the evidence indicates that the Veteran voluntarily retired after 26 years at the same job, and the Board finds that the evidence shows that his disability is productive of no more than moderate symptomatology. See also January 2003 report from Vista Behavioral Health Associates (VHBA) (noting, "Following his retirement in the fall, he began a consulting business and that is now keeping him busy five days a week"); April 2003 VHBA report (noting that the Veteran "has been overwhelmed by how busy his consulting business is," and that he "had to cut back on the amount of time he devotes to it"). Importantly, the report of the QTC examiner overall would not support this finding. As noted above, this examination showed that his orientation, communication, speech, concentration, and memory, were within normal limits, and that his appearance and hygiene, behavior, and thought processes, were characterized as "appropriate." There were no panic attacks, delusions, hallucinations, obsessive-compulsive behavior, suicidal or homicidal ideations, or impairment of judgment. The Axis V diagnosis was a GAF score of 53, and this is evidence of no more than moderate symptomatology. See QRDC DSM-IV. While the QTC psychiatric examination finding of April 2010, out of context to the other findings cited above, would provide evidence in support of this claim, it is important for the Veteran to understand that there is a significant amount of evidence in this claims file that does not support the current evaluation, let alone a higher evaluation, as noted above. Without consideration of the QTC examination there would be little to support the current 50% evaluation as there is significant evidence of the Veteran's ability to function contained with the claims file. A detailed review of the Veteran's statements over time support the factual finding of a person with a high level of functioning, many of those fact being cited above, with very few if any of the example symptoms for the 50% evaluation, let alone a 70% evaluation . In effect, his own statement to his health care providers, overall, provide, overall, highly probative evidence against his own claim. In summary, there is insufficient evidence of such symptoms as (for example only) suicidal ideations, obsessional rituals that interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, spatial disorientation, or neglect of personal appearance and hygiene, nor are the other demonstrated symptoms shown to have resulted in the required level of impairment in most of the referenced areas. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) (38 C.F.R. § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas). The Board therefore finds that the Veteran's symptoms are not of such severity to approximate, or more nearly approximate, the criteria for a rating in excess of 50 percent under DC 9440. See 38 C.F.R. § 4.7. C. Conclusion In deciding these claims, the Board acknowledges that an appellant is generally considered to be competent to report symptoms of his psychiatric disability, and tremors. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). When deciding claims for increased disability ratings, the Board must particularly consider the credibility of a claimant's statements reporting symptoms of a "personal affliction." See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Board has considered the statements of the Veteran and his wife, regarding their observations of his tremors, and psychiatric symptoms. However, lay persons are not competent to identify a specific level of disability for either of the disabilities on appeal, according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service-connected disabilities has been provided by VA medical professionals who have examined him. The medical findings directly address the criteria under which these disabilities are evaluated. In addition, the Board points out that the previously discussed evidence shows that the Veteran has provided contradictory testimony as to the frequency of his tremors, as well as the reasons for his retirement. The Board finds the medical evidence to more competent and probative, and it is therefore accorded greater weight than the Veteran's subjective complaints of increased symptomatology, and his spouse's testimony. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Consideration has also been given to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or 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) (2013); Thun, 22 Vet. App. at 116. The schedular evaluations in this case are not inadequate. Evaluations in excess of 10 percent and 50 percent are provided for certain manifestations of the service-connected disabilities in issue, which have been discussed. The evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disabilities, as the criteria assess the level of occupational and social impairment attributable to the Veteran's symptoms, and the level of functioning. In short, there is nothing exceptional or unusual about the Veteran's disabilities because the rating criteria reasonably describe his disability levels and symptomatology. Thun, 22 Vet. App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the evidence of record does not show that either of his disabilities has caused him to miss work, or that they have resulted in any hospitalizations. The evidence indicates that the Veteran voluntarily retired in 2002, after 26 years at the same job, and that he began his own consulting business shortly thereafter. Whatever subsequently happened with that business, the Board has determined that the Veteran's service-connected disabilities in issue are not shown to have result in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. In deciding the Veteran's claims, the Board has considered the determinations in Fenderson, and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. As noted above, the Board does not find evidence that the Veteran's evaluations should be increased for any other separate period based on the facts found during the whole appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to increased compensation during any time within the appeal period. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the disabilities on appeal such that an increased rating is warranted. In reaching these decisions, the Board considered the benefit- of-the-doubt rule; however, as the preponderance of the evidence is against the appellant's claims, such rule is not for application. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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. 38 U.S.C.A. § 5103(a) ; 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his prior representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. With regard to the claim for an increased rating for an adjustment disorder, the Veteran was notified via a letter dated in November 2009, of the criteria for establishing an increased rating, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates. This letter accordingly addressed all notice elements. Nothing more was required. The matter was then readjudicated as recently as February 2012. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). With regard to the claim for an increased initial evaluation for tremors of the head and neck, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled; no additional § 5103(a) notice is required. Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service treatment reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's VA and non-VA records. In this regard, at his October 2012 hearing, the Veteran stated that his private therapist had a policy of only releasing summary letters about his treatment, as opposed to her actual treatment reports. These summaries have been obtained. See reports from C.H., LPC. The Veteran has been afforded examinations. In May 2011, the Board remanded these claims. The Board requested that all the Veteran's records dated as of August 2008 be obtained from the Houston VAMC, and this has been done. The Board directed that a duty-to-assist letter be sent to the Veteran so that he could identify any other relevant treatment, and in May 2011, this was done. There is no record to show any other treatment was subsequently identified. Finally, the Board directed that the Veteran be afforded a VA examination for his tremors, and in June 2011, this was done. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). In October 2012, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge (VLJ). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the October 2012 hearing, the VLJ identified the issues on appeal. Also, information was solicited regarding the current severity of his symptoms. The testimony does not indicate that there are any outstanding medical records available that would support his claims. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER Prior to May 3, 2004, a compensable evaluation for service-connected tremors of the head and neck is denied. As of May 3, 2004, a rating in excess of 10 percent for service-connected tremors of the head and neck is denied. A rating in excess of 50 percent for service-connected adjustment disorder, with anxious features, and posttraumatic stress disorder, is denied. REMAND The Veteran's October 2012 hearing transcript shows that the Veteran raised a claim for a total rating on the basis of individual unemployability due to service-connected disability (TDIU). This claim has not yet been adjudicated by the agency of original jurisdiction. However, in Rice v. Shinseki, 22 Vet. App. 447 (2009) (per curiam) the Court stated that when the issue of entitlement to a TDIU rating for a particular service-connected disability or disabilities is raised in connection with a claim for an increased rating for such disability or disabilities, the Board has jurisdiction to consider that issue. The Court indicated that if the Board determines that further action by the RO is necessary with respect to the issue, the Board should remand that issue. In this case, the Veteran has not yet been afforded VCAA notice with regard to his TDIU claim. On remand, he should be afforded such notice. Accordingly, the case is REMANDED for the following actions: 1. Send the Veteran a VCAA notice letter on the issue of entitlement to a TDIU. 2. Develop and adjudicate the issue of entitlement to TDIU. 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. 2013). ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs