Citation Nr: 1513034 Decision Date: 03/26/15 Archive Date: 04/03/15 DOCKET NO. 11-17 751 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for left ear hearing loss. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for gastritis, claimed as gastroesophageal reflux disease (GERD). 5. Entitlement to an increased disability rating (or evaluation) in excess of 10 percent for post concussive headaches. 6. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD), in excess of 0 percent for the period from June 15, 2009 to September 23, 2011, and in excess of 10 percent for the period from September 23, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD B. J. Dempsey, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from January 2004 to December 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The issue of service connection for GERD has been re-characterized to one of service connection for gastritis to encompass the claimed symptoms of vomiting and heartburn, and to better comport with the medical evidence of record. See Brokowski v. Shinseki, 23 Vet. App. 79, 84-85 (2009). In a July 2013 rating decision, the RO granted an increased rating of 10 percent for PTSD, effective September 23, 2011, resulting in the staged rating issue listed on the cover sheet of this decision. In September 2014, the Board remanded the matter to provide the Veteran with a Board videoconference hearing. In January 2015, at a Board videoconference hearing, the Veteran provided testimony relevant to the appeal from the RO in Denver, Colorado, before the undersigned Veterans Law Judge in Washington, DC. A copy of the hearing transcript has been associated with the electronic file on the Veterans Benefits Management System (VBMS). Accordingly, the additional development instructed in the September 2014 Board Remand has been completed and the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has reviewed the electronic files on "Virtual VA" and VBMS to ensure a complete review of the evidence in this case. The issue of service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran sustained acoustic trauma during service, including during combat. 2. The Veteran currently has a right ear hearing loss disability for VA compensation purposes, but does not yet have a current left ear hearing loss disability for VA compensation purposes. 3. The Veteran has experienced "continuous" symptoms of right and left ear hearing loss since service separation. 4. The Veteran has a current gastritis disability. 5. The Veteran is currently service connected for post concussive headaches. 6. The current gastritis disability is proximately due to or the result of medication to treat the service-connected post concussive headaches. 7. For the entire rating period from June 15, 2009, the post concussive headache disability has manifested at least five headaches per week that last several hours, and occasional headaches that are accompanied by more severe pain and photosensitivity. 8. For the rating period from June 15, 2009 to September 23, 2011, the service-connected PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms including anxiety attacks, depression, and blunted affect. 9. For the rating period from September 23, 2011, the service-connected PTSD has resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms including panic attacks, social isolation, depression, and intrusive thoughts. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for right ear hearing loss have been met. 38 U.S.C.A. §§ 1110, 1111, 1112, 1154(b), 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(d), 3.307, 3.309, 3.385 (2014). 2. The criteria for service connection for left ear hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1111, 1112, 1154(b), 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(d), 3.307, 3.309, 3.385 (2014). 3. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for gastritis, to include as secondary to service-connected post concussive headaches, have been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2014). 4. Resolving reasonable doubt in the Veteran's favor, for the entire rating period from June 15, 2009, the criteria for an increased disability rating of 30 percent for post concussive headaches have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8045-8100 (2014). 5. Resolving reasonable doubt in the Veteran's favor, for the entire rating period from June 15, 2009, the criteria for an increased disability rating of 30 percent for PTSD, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 8045-9411 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2014). As an initial matter, the Board notes that the claims for service connection for right ear hearing loss, service connection for gastritis, and an increased rating for post concussive headaches have been considered with respect to VA's duties to notify and assist. Given the favorable outcomes (grants of the benefits sought on appeal), further explanation of how VA has fulfilled the duties to notify and assist on these issues is not necessary. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim or claims; (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). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status, (2) existence of a disability, (3) a connection between a veteran's service and the disability, (4) degree of disability, and (5) effective date of the disability. Id. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In a November 2009 letter sent prior to the initial denial of the claims in May 2010, the RO notified the Veteran about the evidence not of record that was necessary to substantiate the claims, VA and the Veteran's respective duties for obtaining evidence, and how disability ratings and effective dates are assigned. Thus, the Board concludes that VA satisfied its duties to notify the Veteran. The Board also concludes that VA has satisfied its duties to assist the Veteran. VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, VA examination and medical opinion reports, and the Veteran's written statements. Regarding the issue of an increased disability rating for PTSD for the period from June 15, 2009 to September 23, 2011, the rating period includes VA examination reports from December 2009 and March 2010. In both instances, the VA examiner discussed PTSD symptoms with the Veteran, received a history from the Veteran, provided clinical observations, and reported on the relevant disability rating criteria. For these reasons, the Board finds that the December 2009 and March 2010 VA medical examination reports are adequate for deciding the increased rating appeal for the period from June 15, 2009 to September 23, 2011. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As to the issue of left ear hearing loss, VA examined the Veteran's hearing in March 2010. The VA examiner reviewed the medical history, reported on the results of audiological testing, and provided the requested medical opinion regarding the etiology of the Veteran's hearing loss with supporting rationale. For these reasons, the Board finds that the March 2010 VA audiological examination is adequate for rating purposes, and that no further medical examination or opinion is needed. See id. As indicated under the facts and circumstances in this case, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. See Mayfield, 444 F.3d at 1328. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of the issues addressed on the merits in this decision. Service Connection Legal Criteria and Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013) (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). Sensorineural hearing loss (organic disease of the nervous system) is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) apply to the Veteran's claim for service connection for hearing loss. With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as sensorineural hearing loss (an organic disease of the nervous system), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. For purposes of applying VA laws, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. VA regulations do not preclude service connection for a hearing loss which first met VA's definition of disability after service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In the case of a veteran who engaged in combat with the enemy in a period of war, "satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service." See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids a veteran by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. at 312. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau, 492 F.3d at 1372). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Hearing Loss The Veteran asserts that a current bilateral hearing loss disorder is related to acoustic trauma sustained during service in Iraq. Specifically, the Veteran attributes a current hearing loss disorder to combat noise exposure, including gunfire, mortars, bombs, and improvised explosive devices. See January 2015 Board hearing at 4. The Board finds that the Veteran sustained acoustic trauma in service, including during combat. During the January 2015 Board hearing, the Veteran testified that he was exposed to the sounds of gunfire, mortars, bombs, and improvised explosive devices while serving in Iraq. Id. The DD Form 214 reflects service in Iraq, including service in a designated imminent danger pay area, as well as a military occupational specialty of cannon crewmember. The Board finds that the Veteran's competent lay account of his duties in service and exposure to combat noise are consistent with the circumstances, conditions, and hardships of his service and are, therefore, credible. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). For these reasons, the Board finds that there was in-service acoustic trauma. The Board finds that the Veteran currently has a right ear hearing loss disability for VA compensation purposes, but does not yet have a current left ear hearing loss disability for VA compensation purposes. In March 2010, the Veteran received a VA audiology examination to assess complaints of hearing loss. The audiogram included in the examination report shows that puretone thresholds, in decibels (dB), were as follows: HERTZ (Hz) 500 1000 2000 3000 4000 RIGHT 15 10 25 45 35 LEFT 10 10 20 25 30 Speech recognition scores using the Maryland CNC Wordlists were recorded as 100 percent in both ears. These results establish a current right ear hearing loss disability (audiometric test score of 40 dB or greater) that meets the standards of 38 C.F.R. § 3.385; however, the results do not establish a current left ear hearing loss disability. The left ear impairment was not measured to have a puretone threshold of 40 dB or greater at any frequency, puretone thresholds of 26 dB or greater in at least three frequencies, or a speech recognition score of 94 percent or worse. 38 C.F.R. § 3.385. While the left ear hearing impairment does not meet the criteria for a hearing loss disability for VA compensation purposes, the VA examiner specifically diagnosed bilateral sensorineural hearing loss in both ears. The Board further finds that the evidence is at least in equipoise on the question of whether symptoms of the right and left ear hearing loss were continuous after service separation. During the January 2015 Board hearing, the Veteran testified that symptoms of hearing loss began in service and have been continuous since onset. See Board hearing transcript at 6-7. The Veteran further testified that there has been no significant noise exposure since service separation. See id. at 8. The Veteran previously submitted a claim for service connection for a right ear disorder; however, the claim was denied because there was no current diagnosis. See November 2007 rating decision. Although the medical evidence does not include treatment for complaints of a right ear hearing loss disability after service, the aforementioned claim for service connection was submitted within three months of service separation. For these reasons, and after resolving reasonable doubt in the Veteran's favor, the Board finds that symptoms of the left and right ear hearing loss have been continuous since service separation so as to meet the criteria for presumptive service connection for right ear sensorineural hearing loss. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309. Because the Board is granting the Veteran's claim for service connection for a right ear hearing loss disability on a presumptive theory of entitlement, the Board does not reach the theory of direct service connection under 38 C.F.R. § 3.303(d). As to the left ear hearing impairment, in evaluating a service connection claim, evidence of a current disability is an essential element, and where not present, the claim under consideration cannot be substantiated. See Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), citing Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Compensation for service-connected injury is limited to those claims which show a present disability"). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). As indicated above, although the Veteran has recognized in-service acoustic trauma and continuous symptoms of left ear hearing loss since service, the evidence does not show a left ear hearing loss disability for VA compensation purposes. 38 C.F.R. § 3.385. For this reason, the weight of the evidence is against finding a current left ear hearing loss disability that would permit a grant of service connection for left ear hearing loss (until the Veteran has a left ear hearing loss that meets the criteria of 38 C.F.R. § 3.385). A current left ear hearing loss disability for VA compensation purposes notwithstanding, the remaining elements for presumptive service connection - in this case, acoustic trauma in service and continuous symptoms of left ear hearing loss since service separation - under 38 C.F.R. § 3.309(a) have been met. Service Connection for Gastritis During the January 2015 Board hearing, the Veteran contended that a current GERD disorder began in service. Specifically, the Veteran explained that chronic vomiting began while serving in Iraq. See Board hearing transcript at 13. The Board finds that the Veteran has a current gastritis disorder, but not a current GERD disorder. VA examined the Veteran for stomach and duodenal conditions, including GERD, in December 2011. The VA examiner diagnosed gastritis, but not GERD. The medical history included on the December 2011 VA examination report reflects that the Veteran reported epigastric pain and burning after taking ibuprofen, and that these symptoms occur about every other day. The Veteran also reported that the symptoms began in 2005, when the Veteran began taking ibuprofen for headaches. As to the non-diagnosis for GERD, the VA examination report also states that the Veteran reported that he first raised concerns over these esophageal symptoms in October 2009, and that the consulting nurse thought it was GERD. This history matches the Veteran's January 2015 Board hearing testimony, during which the Veteran described being diagnosed with GERD at a VA facility. See Board hearing transcript at 14. VA treatment records first list GERD as an active problem in October 2009. Despite this evidence of a current GERD diagnosis, the December 2011 VA examiner explained that, while a VA nurse "thought it was GERD," the Veteran reported that the epigastric pain and burning "clearly coincide with ibuprofen use." Accordingly, the VA examiner did not diagnose GERD; therefore, the Board finds that the weight of the lay and medical evidence is against finding a current GERD disorder. The Board next finds that the Veteran is currently service connected for post concussive headaches. Service connection for post concussive headaches was granted in a November 2007 rating decision with an effective date of December 19, 2006. On review of all the evidence, lay and medical, the Board finds that the evidence is in relative equipoise on the question of whether the current gastritis disability is proximately due to or the result of service-connected post concussive headaches, or more specifically, medication used to treat the service-connected post concussive headaches. As noted above, the Veteran has reported that gastritis symptoms clearly coincide with ibuprofen use for post concussive headache pain relief. The Veteran reported that gastritis symptoms began in 2005, which closely approximates the onset date of post concussive headaches, which began in March 2005. The Veteran is competent to report use of ibuprofen to treat headache symptoms, as well as epigastric pain and burning that follows ibuprofen use. See Layno, 6 Vet. App. 465; Jandreau, 492 F.3d at 1377; see also April 2010 VA examination report (noting ibuprofen prescription for headaches). The Board finds the Veteran's testimony before the Board and statements to VA medical providers to be consistent and credible. For these reasons, and after resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for secondary service connection for gastritis have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. Because the Board is granting the claim for service connection for gastritis on a secondary theory of entitlement, the Board does not reach the theory of direct service connection under 38 C.F.R. §§ 3.303(a) or 3.303(d). Disability Rating Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining the disability rating, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco, 7 Vet. App. at 58. The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. Increased Rating for Post Concussive Headaches Service concussion for post concussive headaches was granted in a November 2007 rating decision, which assigned a 10 percent disability rating, effective December 19, 2006. On June 15, 2009, VA received a request for an increased rating based on more severe headaches. See June 2009 VA Form 21-4138. For the entire rating period from June 15, 2009, the service-connected post concussive headache disability has been rated under 38 C.F.R. § 4.124a, Diagnostic Code 8045-8100. Hyphenated Diagnostic Codes are used when a rating under one Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2014). The additional Code, shown after the hyphen, represents the basis for the rating, while the primary Code indicates the underlying source of the disability. In this case, Diagnostic Code 8100 is used for rating headache disabilities, while Diagnostic Code 8045 indicates the schedular rating criteria used to rate the residuals of a traumatic brain injury (TBI). As an initial matter, the Board notes that the Veteran is separately rated for residuals of a TBI. See May 2010 rating decision. Ratings for a TBI encompass a range of symptoms including cognitive impairment, emotional/behavioral dysfunction, and physical dysfunction; however, distinguishable symptoms, such as headaches, may be rated separately. See 38 C.F.R. § 4.124a, Diagnostic Code 8045. Here, the service-connected post concussive headaches have been rated separately; as such, the Board's analysis will follow the rating criteria used to rate headache disabilities. Rating the service-connected headache disability with consideration of the other service-connected TBI symptoms, which are accounted for in the separate service-connected TBI disability rating, would constitute impermissible pyramiding. See 38 C.F.R. § 4.14; see also May 2010 rating decision (assigning a noncompensable disability rating for symptoms including insomnia). Under Diagnostic Code 8100, a 10 percent rating is assigned for migraine headaches when a veteran has characteristic prostrating attacks averaging once in two months over the last several months. 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. After a review of all the evidence, lay and medical, the Board finds that the evidence is at least in relative equipoise on the question of whether, for the entire increased rating period from June 15, 2009, the evidence more nearly approximates the criteria for a higher disability rating of 30 percent. For the entire increased rating period from June 15, 2009, the service-connected post concussive headache disability has manifested at least five headaches per week that last several hours, and occasional headaches that are accompanied by more severe pain and photosensitivity. In a June 2009 VA Form 21-4138, the Veteran described experiencing four to six headaches per week, each lasting for several hours. The Veteran explained that the headache pain is debilitating, but that he was able to work through the pain. VA treatment records include a single treatment record for headaches. In October 2009, the Veteran reported experiencing five headaches per week. The Veteran stated that he was able to function through headache pain. VA examined the service-connected headaches in April 2010. During the April 2010 VA examination, the Veteran reported experiencing approximately five headaches per week, each lasting approximately three hours. The Veteran explained that more severe headaches, which occur twice per month, are accompanied by photosensitivity. When VA examined the headaches again in September 2011, the Veteran reported that post concussive headache symptoms had not changed since the April 2010 VA examination. During the January 2015 Board hearing, the Veteran testified that the headache disability manifested seven headaches per week. See Board hearing transcript at 17. The Veteran estimated that the headaches can last from three hours up to the entire day. Id. at 18. The Veteran described the pain as debilitating, but also testified that he is able to work through the headache pain. Id. at 17, 19. In sum, the lay and medical evidence demonstrates a fluctuating disability picture throughout the rating period from June 15, 2009; however, the post concussive headache disability has consistently manifested at least five headaches per week that last several hours, and occasional headaches that are accompanied by more severe pain and photosensitivity. The Veteran has indicated that pain can be severe, but that he is generally able to function through headache pain when using prescribed medication (ibuprofen). Resolving reasonable doubt in the Veteran's favor, the Board finds that the headaches are of such frequency and severity that they more nearly approximate the criteria for the 30 percent rating under Diagnostic Code 8100 for the entire increased rating period from June 15, 2009. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 38 C.F.R. §§ 4.3, 4.7, 4.124a. During the January 2015 Board hearing, the Veteran specifically indicated that a 30 percent increased disability rating would fully satisfy the appeal as to this issue. See Board hearing transcript at 29. As such, this is a full grant of the benefits sought on appeal as to this issue. This is distinguished from a case where a veteran does not express satisfaction with a partial increased rating during an appeal that is less than the maximum schedular rating. See A.B. v. Brown, 6 Vet. App. 35, 39 (1993) (recognizing that a claimant may limit the claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum allowed by law for a particular service-connected disability). The Board finds the Veteran's waiver of the remaining aspects of the appeal for an increased rating for post concussive headaches was knowing and intelligent, was made with representation and in the presence of his representative, and is consistent with the Veteran's testimony and the evidence of record. Nevertheless, in finding that the Veteran's waiver of a disability rating in excess of 30 percent was consistent with the evidence, the Board has considered all the lay and medical evidence and finds that at no time during the increased rating period from June 15, 2009 has the Veteran experienced completely prostrating headaches, with prolonged attacks, and the headaches have not produced severe economic inadaptability, as required for a higher disability rating of 50 percent. In the June 2009 VA Form 21-4138, the Veteran stated that headache pain made finding and keeping employment difficult; however, the Veteran attributed the difficulty to coworkers' misconceptions about his mood rather than debilitating pain. In written statements, oral testimony, and during VA examination, the Veteran has consistently indicated his ability to work through headache pain. In a January 2015 letter, the Veteran's employer indicated that the Veteran missed a full seven days of work over the previous two months "due to issues with migraines and post traumatic stress." While the January 2015 letter does provide evidence that headache pain in part caused the Veteran to miss up to seven days of work over a two month period due to post concussive headaches, it also equally attributes the days missed from work to the separate disability of PTSD. For these reasons, the Board finds that the weight of the evidence is against finding that the post concussive headaches have been so severe so as to produce severe economic inadaptability. As such, the Board finds that a higher 50 percent disability rating for service-connected post concussive headaches is not warranted. 38 C.F.R. §§ 4.3, 4.7. Increased Rating for PTSD Service connection for an anxiety disorder (later recharacterized as service connection for PTSD) was granted in a November 2007 rating decision by the RO, which assigned an initial noncompensable (0 percent) disability rating, effective December 19, 2006. On June 15, 2009, VA received a request for an increased disability rating for worsening symptoms of anxiety. See June 2009 VA Form 21-4138. In a July 2013 rating decision, the RO granted an increased rating of 10 percent for PTSD, effective September 23, 2011, creating a staged rating of 0 percent for the period from June 15, 2009 to September 23, 2011, and 10 percent for the period from September 23, 2011. For the entire increased rating period, service-connected PTSD has been rated under 38 C.F.R. § 4.130, Diagnostic Code 8045-9411. Similar to the discussion above, Board notes that PTSD has been specifically been rated under Diagnostic Code 8045-9411 because PTSD is a derivative and independently ratable disorder related to the service-connected residuals of a TBI. See 38 C.F.R. §§ 4.27, 4.124a (2014). With particular regard to rating PTSD, the analysis below does not include consideration of sleep impairment because consideration of sleep impairment, which is accounted for in the separate service-connected TBI disability rating, would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. Psychiatric disabilities are evaluated under the General Rating Formula for Mental Disorders. Upon review, the Board finds that no other diagnostic code or rating schedule would be appropriate in the evaluation of the Veteran's psychiatric disability. Under the General Rating Formula for Mental Disorders, a rating of 0 percent is warranted when a mental condition has been diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating may be assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or when symptoms are controlled by continuous medication. Id. A rating of 30 percent is warranted when a psychiatric disability manifests occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the 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 his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated 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." It was further noted that "§ 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." In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32 (4th ed. 1994)). A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is 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). A GAF score of 41-50 indicates 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 of 51-60 indicates 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). A GAF score of 61-70 indicates mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. DSM-IV at 46-47. The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard, 9 Vet. App. at 267; Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the rating issue. The GAF score must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2014). June 15, 2009 to September 23, 2011 For the rating period from June 15, 2009 to September 23, 2011, the service-connected PTSD is rated as noncompensable. As noted above, the Veteran submitted a claim for an increased rating based on anxiety on June 15, 2009. See June 2009 VA Form 21-4138. After reviewing all the evidence, lay and medical, the Board finds that, for the entire rating period from June 15, 2009 to September 23, 2011, the evidence is in relative equipoise on the question of whether the service-connected PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms including anxiety attacks, depression, and blunted affect, as described for an increased disability rating of 30 percent under Diagnostic Code 9411. In the June 2009 VA Form 21-4138, the Veteran stated that he experiences daily anxiety attacks. In an August 2009 VA Form 21-4138, the Veteran described feelings of social isolation. The Veteran explained that he is able to work but that, for reasons the Veteran did not specify, he is unable to find or maintain employment. The Veteran also noted depression. VA treatment records from July 2009 include a mental triage note, wherein the Veteran is shown to have reported a part-time job, with plans to hold the job until school began in the fall. The Veteran stated that he keeps anxiety in check, and that symptoms were less severe than in the past. The Veteran denied feeling depressed or reduced interest in activities. By October 2009, the Veteran was unemployed but enrolled in school. See October 20, 2009 treatment record. In November 2009, a VA clinician provided a GAF score of 50 based on unspecific symptoms, although the Veteran reported that most of his symptoms had resolved. VA provided a mental health assessment in December 2009. During the assessment, the Veteran reported that PTSD symptoms had improved during the previous weeks. The Veteran noted that he was living with a girlfriend, and was enrolled in vocational school, where he had made friends. The VA clinician observed a "blunted/restricted/constricted" affect, but the remaining observations from a mental status examination were normal, other than visual hallucinations attributed to migraines (colored orbs). The VA clinician provided a GAF score of 51, which is indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. The assessment notes that in October 2009, the Veteran reported symptoms of hypervigilence, hyperarousal, anger, sadness, hopelessness, and difficulty remembering things; however, at the December 2009 assessment, the Veteran indicated that those symptoms had subsided. VA examined the PTSD again in March 2010. The VA examiner expressed that the Veteran "may have had a [PTSD] at one time," and that PTSD did not appear to be causing any clinical impairment. A general description of "arousal symptoms" were said to be transient, currently stable, and in partial remission. The VA examiner stated that the Veteran does not need psychiatric medications, and that, based on review of other psychiatric treatment notes, the Veteran has a tendency to exaggerate his levels of symptomatology. The GAF score was recorded as 85. In June 2011, the Veteran submitted a letter describing hyperarousal, violent thoughts, anger, disconnection from others, panic attacks, nightmares, and desire for isolation. In sum, for the rating period from June 15, 2009 to September 23, 2011, the service-connected PTSD manifested symptoms including has manifested symptoms including anxiety attacks, depression, blunted affect, hyperarousal, anger, sadness, nightmares, desire for isolation, violent thoughts, blunted affect, hopelessness, and difficulty remembering things. The Veteran described difficulty finding and maintaining work, but these were not clearly attributed to anxiety attacks, depression, blunted affect, or any other PTSD symptom. In contrast, the evidence demonstrates part time employment and enrollment in vocational school. The Veteran described improving symptoms; however, even at an improved state, VA clinicians provided a GAF scores of 50 and 51, indicating serious to moderately severe PTSD symptoms, or serious to moderate difficulty in social, occupational, or school functioning. While the evidence also includes a GAF score of 85 and PTSD symptoms described as in remission in March 2010, given the evidence of worsening symptoms by June 2011, it is as likely as not that this was a temporary period of improvement. After resolving reasonable doubt in the Veteran's favor, the Board finds that, for the period from June 15, 2009 to September 23, 2011, the occupational and social impairment due to service-connected PTSD symptoms more nearly approximated the criteria for an increased disability rating of 30 percent. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Within this context, the Board also finds that, for the rating period from June 15, 2009 to September 23, 2011, the weight of the lay and medical evidence is against finding that that the service-connected PTSD met or more nearly approximated the criteria for an increased disability rating of 50 percent. Although the evidence reflects that the Veteran reported symptoms of hypervigilence, hyperarousal, anger, sadness, hopelessness, and difficulty remembering things, the Veteran frequently emphasized headaches, memory problems, and sleeping impairment as the main symptoms stemming from a TBI. Further, during the rating period from June 15, 2009 to September 23, 2011, the Veteran stated on more than one occasion that the severity of symptoms had subsided. The Veteran has not asserted and the evidence does not show several of the symptoms approximating a 50 percent disability rating including flattened affect, circumstantial, circumlocutory, or stereotyped speech, difficulty in understanding complex commands, or impaired abstract thinking. As noted above, the Veteran reported part-time employment and enrollment in vocational school without reporting any impairment due to PTSD symptoms such as anxiety, depression, blunted affect, hypervigilence, hyperarousal, anger, sadness, hopelessness, or difficulty remembering things. Although the evidence does include a GAF score of 50 from November 2009, indicating serious symptoms or any serious impairment in social, occupational, or school functioning, the remainder of the evidence generally supports finding that the PTSD manifested a moderate disability picture, as the Veteran more often reported reduced symptoms and no impairment at school, work, or in social settings, other than disliking crowds and occasional short term memory difficulty. Although the Veteran described a desire for social isolation, he also described a comfortable arrangement living with his girlfriend, friends at school, and the ability to work and attend school without significant disruption due to PTSD symptoms. Additionally, the severity of the Veteran's PTSD symptoms were considered when resolving reasonable doubt to find that the severity of the PTSD symptoms more nearly approximated the criteria for a 30 percent disability rating. It was noted by the March 2010 VA examiner that the Veteran showed a tendency to exaggerate his symptoms, based on the results of psychological assessment tests. For these reasons, the Board finds that, for the rating period from June 15, 2009 to September 23, 2011, the weight of the evidence is against finding occupational and social impairment with reduced reliability and productivity due to PTSD symptoms including anxiety, depression, blunted affect, hypervigilence, hyperarousal, anger, sadness, hopelessness, or difficulty remembering things. Because preponderance of the evidence is against the appeal for an increased rating in excess of 30 percent for PTSD for the rating period from June 15, 2009 to September 23, 2011, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. From September 23, 2011 For the rating period from September 23, 2011, the service-connected PTSD has been rated as 10 percent disabling. In a July 2013 rating decision, the RO assigned the 10 percent disability rating from the date of a VA examination showing worsening symptoms of PTSD. After reviewing all the evidence, lay and medical, the Board finds that, for the rating period from September 23, 2011, the evidence is in relative equipoise on the question of whether the service-connected PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms including panic attacks, social isolation, depression, and intrusive thoughts. VA examined the PTSD on September 23, 2011. During the VA examination, the Veteran reported PTSD symptoms including nightmares, intrusive thoughts, flashbacks to Iraq, feelings of detachment from others, and hyperarousal. The Veteran stated that he avoids dealing with people. The Veteran denied feelings of sadness, low energy, and low motivation, but described depression characterized by a temper, occasional crying, and hatred. The Veteran reported feeling homicidal at times, but no plans and no specific person that he focuses on. The Veteran described doing well in school and in business. The September 2011 VA examiner opined that the Veteran may have been overstating the severity of PTSD symptoms and provided a GAF score of 75. Specifically, the VA examiner stated that "I suspect when [the Veteran] describes his symptoms he overstates his situation. Other providers have also described this." The VA examiner characterized the PTSD symptoms as having created occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. During the January 2015 Board hearing, the Veteran testified that PTSD had manifested symptoms including frequent panic attacks and social isolation. See Board hearing transcript at 21-27. The Veteran described anger outbursts at work. Id. at 25. The Veteran described that PTSD symptoms have worsened since finishing school in December 2012, which has been accompanied by financial stress. Id. at 27. In sum, the evidence for the rating period prior to September 23, 2011 more nearly approximated the criteria for a 30 percent disability rating based on occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms including anxiety attacks, depression, and blunted affect. For the rating period from September 23, 2011, the evidence demonstrates similar PTSD symptoms including panic attacks, depression, social isolation, and intrusive thoughts. The September 2011 VA examiner opined that the Veteran may have been overstating the severity of PTSD the symptoms, characterized the severity of the PTSD symptoms as consistent with a 10 percent disability rating, and provided a GAF score of 75. At the same time, the Veteran reported doing well in school and in business, which does not suggest any notable occupational impairment. Nevertheless, the Veteran later indicated that PTSD symptoms had worsened since finishing school in December 2012. As such, given that the Veteran was in school while PTSD symptoms more nearly approximated a 30 percent disability rating (after resolving reasonable doubt in the Veteran's favor), the Board finds that the VA examiner's opinion is outweighed by the other evidence relating to the severity of the Veteran's PTSD. More specifically, the VA examiner's suggestion that the Veteran may have been overstating the severity of the symptoms does not overcome the presence of the those symptoms, or reduce the estimated severity to the mild disability picture estimated by the VA examiner. The Veteran subsequently reported that symptoms worsened approximately 15 months after the September 2011 VA examination when school finished in December 2012. While the severity of the symptoms may have fluctuated at times, the evidence does not demonstrate that the severity of the PTSD was significantly dissimilar to the rating period prior to September 23, 2011, when the PTSD symptoms more nearly approximated the criteria for a 30 percent disability rating. For these reasons, and after resolving reasonable doubt in the Veteran's favor, the Board finds that, for the rating period from September 23, 2011, the occupational and social impairment due to service-connected PTSD symptoms more nearly approximates the criteria for an increased disability rating of 30 percent. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Within this context, the Board also finds that, for the rating period from September 23, 2011, the weight of the lay and medical evidence is against finding that that the service-connected PTSD met or more nearly approximated the criteria for an increased disability rating of 50 percent. Similar to the evidence for the rating period from June 15, 2009 to September 23, 2011, the evidence for the rating period from September 23, 2011 also includes a VA examiner's opinion that the Veteran exaggerated the severity of PTSD symptoms during examination. Also similar to the earlier rating period, the evidence for the period from September 23, 2011 does not show several of the symptoms approximating a 50 percent disability rating including flattened affect, circumstantial, circumlocutory, or stereotyped speech, difficulty in understanding complex commands, or impaired abstract thinking. For these reasons, and because the Board has already resolved reasonable doubt in the Veteran's favor when finding that the criteria for a 30 percent disability rating have been more nearly approximated, the Board finds that, for the rating period from September 23, 2011, the weight of the evidence is against finding occupational and social impairment with reduced reliability and productivity due to PTSD symptoms including panic attacks, depression, social isolation, and intrusive thoughts. Because preponderance of the evidence is against the appeal for an increased rating in excess of 30 percent for PTSD for the rating period from September 23, 2011, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2014); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria found in 38 C.F.R. § 4.130 specifically provides for disability ratings based on a combination of history, clinical findings, and symptomatology. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested symptoms including anxiety attacks, depression, blunted affect, hyperarousal, anger, sadness, nightmares, desire for isolation, violent thoughts, blunted affect, hopelessness, and difficulty remembering things. 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, 16 Vet. App. 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. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced; however, in this case, neither has the Veteran asserted, nor has the evidence of record suggested, any such combined effect of multiple service-connected disabilities to create such an exceptional circumstance. The other service-connected disabilities in this case are tinnitus, insomnia, left knee strain, laceration of left long finger, a scar from the left long finger laceration, residuals of a right tibia stress fracture, and following this rating decision, right ear hearing loss and gastritis. For these reasons, the Board finds that the schedular rating criteria are adequate to rate the service-connected PTSD, and referral for consideration of extraschedular rating is not required. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Lastly, the Board has considered whether an inferred claim for a total disability rating based on individual unemployability has been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As noted above, during the period from June 15, 2009 to September 23, 2011, the Veteran stated that he was able to work but that he was unable to find or maintain employment. See August 2009 VA Form 21-4138. The Veteran did not specify whether this employment situation was due to service-connected disabilities; however, additional evidence from this period shows that the Veteran maintained part-time work, was enrolled in school, and reported doing well in business. See September 2011 VA examination. For these reasons, the Board finds that the issue of entitlement to a total disability rating based on individual unemployability has not been reasonably raised by the record or by the Veteran. See Rice, 22 Vet. App. at 453-54. ORDER Service connection for right ear hearing loss is granted. Service connection for left ear hearing loss is denied. Service connection for gastritis is granted. An increased rating of 30 percent for post concussive headaches, but no higher, for the entire rating period from June 15, 2009, is granted. An increased rating of 30 percent for PTSD, but no higher, for the entire rating period from June 15, 2009, is granted. REMAND Service Connection for Hypertension The Veteran contends that a current hypertension disorder is related to service. Specifically, the Veteran asserts that current hypertension, which was first diagnosed after service separation, began in service with a series of high blood pressure readings. See January 2015 Board hearing transcript at 9-11. After a review of the record, the Board finds that additional development is needed before proceeding to appellate review on the issue of service connection for hypertension. A VA examination is required to fulfill VA's duty to assist the Veteran substantiate the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). In disability compensation (service connection) claims, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, VA treatment records reflect a current hypertension disorder. See, e.g., December 22, 2009 VA treatment record. Service treatment records include several blood pressure readings not within normal limits or only slightly within normal limits (i.e., the systolic reading was less than 140 millimeters of mercury and the diastolic reading was less than 90 millimeters of mercury), including in August 2005 (141/97), September 2005 (155/90), October 2005 (155/87), July 2006 (137/82), August 2006 (155/82), and October 2006 (139/89). The Veteran has not been provided with a VA examination or medical opinion on the question of whether the hypertension began during service or is related to service. For these reasons, the Board finds that a VA examination is necessary in this case. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. 79. Accordingly, the issue of service connection for hypertension is REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination to assist in determining the etiology of currently diagnosed hypertension disability. The relevant evidence should be made available to and reviewed by the examiner prior to completion of the examination. All necessary testing should be conducted and all appropriate diagnoses rendered. Based on review of the appropriate records, the examiner should offer the following opinion: Is it as likely as not (i.e., to a probability of 50 percent or greater) that current hypertension had its onset during service or was otherwise causally or etiologically related to service, to include any symptomatology, event, or incident therein? When providing this opinion, the examiner should discuss the high blood pressure readings from August 2005 (141/97), September 2005 (155/90), October 2005 (155/87), July 2006 (137/82), August 2006 (155/82), and October 2006 (139/89). The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If an opinion cannot be rendered without resorting to speculation, the examiner should state whether the inability to provide an opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder. 2. When the development above has been completed, the remanded issues should be readjudicated. If any benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2014). 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 2014). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs