Citation Nr: 1612351 Decision Date: 03/28/16 Archive Date: 04/07/16 DOCKET NO. 10-39 680 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased rating in excess of 10 percent for headaches. 2. Entitlement to a compensable rating for residuals of a left shoulder injury prior to September 1, 2011, and in excess of 10 percent thereafter. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to an initial rating in excess of 10 percent for residuals of a traumatic brain injury (TBI). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and J.N. ATTORNEY FOR THE BOARD R. Casadei, Counsel INTRODUCTION The Veteran served on active duty from February 2003 to February 2007. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran and J.N. testified before the undersigned in a November 2015 Travel Board hearing, the transcript of which is included in the record. This appeal was processed using the Veterans Benefits Management System (VBMS). In evaluating this case, the Board has also reviewed the "Virtual VA" system to ensure a complete assessment of the evidence. The issue of an initial rating in excess of 10 percent for residuals of a TBI is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire rating period on appeal, the Veteran's headache disability is manifested by characteristic prostrating attacks occurring approximately once a month throughout the appeal; however, the Veteran's headaches have not been productive of disability manifested by very frequent and completely prostrating and prolonged attacks that are productive of severe economic inadaptability. 2. For the rating period prior to September 1, 2011, the Veteran's left shoulder disability was manifested by crepitus, aching, stiffness, and pain; limitation of motion was not shown. 3. For the entire rating period on appeal, the Veteran's left shoulder disability has not manifested limitation of motion at shoulder level. 4. For the entire initial rating period on appeal, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, and mood. 5. For the entire initial rating period on appeal, the Veteran's PTSD has not been manifested by total social impairment. CONCLUSIONS OF LAW 1. For the entire rating period on appeal, the criteria for a 30 percent disability rating, but no higher, for headaches have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2015). 2. For the rating period prior to September 1, 2011, the criteria for a 10 percent rating for residuals of a left shoulder injury have been met. 38 U.S.C.A. § 1155 (2014); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2015). 3. For the entire rating period on appeal, the criteria in excess of 10 percent for residuals of a left shoulder injury have not been met. 38 U.S.C.A. § 1155 (2014); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2015). 4. For the entire initial rating period on appeal, the criteria for a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). VA has met its duty to notify and assist the Veteran in this case. In a July 2009 letter, VA informed the Veteran of the evidence necessary to substantiate his claims for service connection and increased ratings, evidence VA would reasonably seek to obtain, and information and evidence for which the Veteran was responsible. The letter also provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's PTSD and TBI claims arise from the Veteran's disagreement with the initial evaluations assigned after the grant of service connection. The courts have held that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The Veteran's service treatment records, VA and private treatment records, the November 2015 Board hearing transcript, and the Veteran's statements have been associated with the claims file. Further, the Veteran was afforded VA examinations in connection with his claims in August 2009 (headaches, left shoulder, PTSD) and March 2015 (headaches and PTSD). 38 C.F.R. § 3.159(c)(4) (2015). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As set forth in greater detail below, the Board finds that the VA examinations obtained in this case are adequate as they are predicated on a review of the claims folder and medical records contained therein; contain a description of the history of the disability at issue; document and consider the Veteran's complaints and symptoms; fully addresses the relevant rating criteria; and contain a discussion of the effects of the Veteran's disabilities on his occupational and daily activities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Further, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained; hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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 (2015). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2015). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal the Board must also 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"). Rating for Headache Disability The Veteran was initially granted service connection for headaches and was assigned a noncompensable rating in a June 2007 rating decision. In a June 2009 statement, the Veteran maintained that his headaches had worsened. In a subsequent December 2009 rating decision, the RO increased the Veteran's rating to 10 percent for his headache disability. The Veteran is seeking a higher rating. The Veteran's headaches have been rated analogously to migraines under Diagnostic Code 8199-8100. See 38 C.F.R. §§ 4.20, 4.124a. Diagnostic Code 8100 provides a 10 percent rating for migraine headaches with characteristic prostrating attacks averaging once in two months over the last several months, a 30 percent rating for characteristic prostrating attacks occurring on average once a month over the last several months, and a 50 percent rating for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The rating criteria do not define "prostrating." By way of reference, however, MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), defines "prostration" as "complete physical or mental exhaustion." A similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), which defines "prostration" as "extreme exhaustion or powerlessness." Upon review of all the evidence of record, both lay and medical, the Board finds that for the entire rating period on appeal, the Veteran's headaches are manifested by characteristic prostrating attacks occurring approximately once a month. The evidence includes an August 2009 VA examination. During the evaluation, the Veteran reported that his headaches had worsened and that they were occurring daily, usually lasting from 4 to 12 hours. He described the headaches as sharp pain, without acute nausea, vomiting, or photophobia. The Veteran reported having to take four to five sick days in the past year as a result of his headaches. He also reported taking two Excedrin migraine tablets twice a day with moderate relief. The examiner did not obtain history of the frequency and duration of the attacks and the description of the level of activity the Veteran could maintain during his attacks. The Veteran was afforded another VA examination in March 2015. During the evaluation, the Veteran reported that his headaches occurred about three times a week, lasting about two hours or more. It was noted that the Veteran was prescribed two medications for his headache disability. Symptoms were noted to include pain on the front side of the head and on the side of his eyes. He also experienced non-headache symptoms associated with his headaches, including nausea, sensitivity to light, sensitivity to sound, and sensitivity to smells. The examiner noted that the duration of a typical headache was for less than one day. The examiner also indicated that the Veteran had characteristic prostrating attacks of migraine pain "with less frequent attacks." These attacks were not noted to be productive of severe economic inadaptability. During the November 2015 Board hearing, the Veteran testified that he would shut himself in a dark room when experiencing a headache. He stated that the nausea and sensitivity to light had been present since 2009. The Veteran also reported that his wife had bought him some blackout curtains so that he could lie in a dark room during his attacks. He also testified that he took medication on a daily basis. J.N. also testified that the Veteran would miss some work as a result of his headaches on a "monthly" basis and stated that the Veteran would put on his sunglasses or lock himself in his vehicle and nap. Upon review of all the evidence of record, lay and medical, the Board finds that the evidence is in equipoise as to whether a rating in excess of 10 percent is warranted for the Veteran's headache disability. The evidence shows that the Veteran has consistently and credibly described his headaches as sharp pain with symptoms of nausea and sensitivity to light. Additionally, during the November 2015 Board hearing, he testified that he had to sometimes leave work due to his headaches. J.N. reported that the Veteran would miss work as a result of his headaches on a "monthly" basis. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's headache disability more nearly approximates prostrating attacks occurring on average once a month over the last several months. As such, a 30 percent rating under Diagnostic Code 8100 is warranted for the entire initial rating period on appeal. The Board further finds that entitlement to a higher rating of 50 percent is not warranted at any point during this appeal. In this regard, the March 2015 VA examiner specifically found that the Veteran's headaches were not productive of severe economic inadaptability. Although the Veteran did report missing some days of work as a result of his headache disability, the March 2015 VA examiner stated that the Veteran's headaches did not significantly impact his ability to work. The Veteran has also been able to maintain employment throughout the appeal period. For these reasons, the Board finds that a 30 percent rating, but no higher, for the Veteran's headache disability under Diagnostic Code 8100 is warranted for the entire rating period on appeal. Rating for Left Shoulder Disability The Veteran has been assigned a 10 percent rating for his left shoulder disability effective September 1, 2011. The Veteran maintains that the 10 percent rating should have been awarded for the entire increased rating period on appeal. See November 2015 Board Hearing Transcript. As such, the Board will consider whether a compensable rating for residuals of a left shoulder injury prior to September 1, 2011, and in excess of 10 percent thereafter is warranted. The Veteran's left shoulder disability has been rated under Diagnostic Code 5201 for limitation of motion of the shoulder. He has been diagnosed with left shoulder tendonitis. The rating criterion for Diagnostic Code 5201 relies on range of motion tests in assessing the severity of a disability. The Veteran is right arm dominant. Under Diagnostic Code 5201, limitation of motion of the (minor) arm to shoulder level (i.e. 90 degrees) warrants a 20 percent rating. Motion limited midway between the side and shoulder level (i.e. less than 90 degrees but more than 25 degrees shoulder motion) warrants a 20 percent rating. Motion limited to 25 degrees or less from the side is rated at 30 percent. The evidence includes an August 2009 VA shoulder examination. During the evaluation, the Veteran reported that he injured his left shoulder falling out of a Humvee in 2004. Residuals included crepitus, aching, stiffness, and pain, usually occurring once a week and lasting all day. It was noted that the Veteran worked as a mechanic and had some difficulty lifting heavy objects in his non-dominant left hand. He was otherwise able to perform the activities of daily living such as operating a motor vehicle, dressing and undressing, and attending the needs of nature without assistance. Upon range of motion testing of the left shoulder, the examiner noted that the Veteran had full range of motion with forward flexion from 0 to 180 degrees, abduction was from 0 to 180 degrees, internal rotation was from 0 to 90 degrees, and external rotation was from 0 to 90 degrees. The Veteran was noted to have mild discomfort at extremes of external rotation. The examiner further indicated that the Veteran did not have heat, redness, or swelling in the left shoulder, but some crepitus was noted with external rotation testing. The Board has reviewed VA treatment records which show that the Veteran has consistently reported left shoulder pain. In a September 1, 2011 VA treatment record, the Veteran reported left shoulder pain for the past three years. He stated that he had increasing pain with lifting overhead. Upon range of motion testing, flexion of the left shoulder was from 0 to 180 degrees, with pain at 170 degrees. Abduction was from 0 to 180 degrees, with pain starting at 140 degrees. Internal and external rotation was from 0 to 90 degrees with pain on external rotations. The Veteran was provided a subacromial steroid injection in the left shoulder. During the November 2015 Board hearing, the Veteran stated that the 10 percent rating assigned in September 2011 should have been assigned back to the date of his claim for increase as he had similar pain on range of motion at the time of the August 2009 VA examination. Based on the above evidence discussed above, the Board finds that a 10 percent rating is warranted for the period prior to September 1, 2011 for the Veteran's left shoulder disability. When limitation of motion is noncompensable under the appropriate code or codes, a rating of 10 percent may be applied to each major joint or group of minor joints affected by limitation of motion. Such limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The shoulder is considered a major joint for these purposes. See 38 C.F.R. § 4.45(f). Here, the evidence, both lay and medical, demonstrates painful motion of the left shoulder prior to September 1, 2011. The August 2009 VA examination report noted that the Veteran had mild discomfort at extremes of external rotation upon range of motion testing. The provisions of 38 C.F.R. § 4.59 establish that a veteran is entitled to a minimum compensable (10 percent) evaluation for painful motion. See also Burton v. Shinseki, 25 Vet. App. 1 (2011). However, evaluations in excess of the minimum compensable rating (10 percent) must be based on demonstrated functional impairment. For this reason, the Board finds that a 10 percent rating is warranted for the Veteran's left shoulder disability for the rating period prior to September 1, 2011. The Board next finds that a rating in excess of 10 percent for the Veteran's left shoulder disability is not warranted for the entire increased rating period on appeal. The weight of the evidence, including the medical evidence discussed above, does not reflect that the Veteran's left shoulder disability is limited in motion to shoulder level as contemplated by the next higher 20 percent rating under Diagnostic Code 5201. While the Veteran has been shown to have some decreased range of motion in the September 2011 VA treatment record, flexion and abduction of the shoulder was beyond 90 degrees (i.e., to shoulder level). Accordingly, a rating in excess of 10 percent is not warranted for the entire increased rating period on appeal under Diagnostic Code 5201. In addition to Diagnostic Code 5201, the Board has considered whether a higher rating would be warranted under other diagnostic codes for the shoulder. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203. Of the remaining diagnostic codes, 5200 (scapulohumeral articulation, ankylosis of), 5202 (other impairment of the humerus), and 5203 (impairment of the clavicle or scapula), the medical evidence of record fails to demonstrate ankylosis of the shoulder, or involvement of the humerus, clavicle, or scapula. Accordingly, the Board focused its analysis on Diagnostic Code 5201. For these reasons, the Board finds that, for the rating period prior to September 1, 2011, a 10 percent rating, but no higher, for residuals of a left shoulder injury is warranted. The Board further finds that, for the rating period beginning September 1, 2011, a rating in excess of 10 percent for residuals of a left shoulder injury is not warranted. Rating for PTSD Disability The Veteran maintains that his PTSD disability is more severe than what is contemplated by the currently assigned 30 percent rating. The Veteran is in receipt of a 30 percent disability rating for PTSD under Diagnostic Code 9411 for the entire rating period on appeal. A rating of 30 percent is warranted for PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is 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); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent disability rating is assigned total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV or DSM 5). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100 reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 61 to 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, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). DSM-IV at 46-47. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated "DSM-5." As the Veteran's claim was certified to the Board after August 4, 2014, the DSM-5 is applicable to this case. According to the DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In reviewing the evidence of record, the Board will consider the assigned GAF score; however, the Board is cognizant that GAF scores are not, in and of themselves, the dispositive element in rating a disability. Rather, GAF scores must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2015). Upon review of the evidence of record, the Board finds that the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, and mood. The evidence includes an August 2009 VA psychiatric examination. During the evaluation, the Veteran reported increased anger and indicated that he was afraid that he would lose his girlfriend as a result of his anger outbursts. Other symptoms reported included depressed mood of moderate degree, lack of energy of moderate degree, and mild feelings of hopelessness. The Veteran reported that although he had a girlfriend, he did not have any other social relationships due to his decreased level of comfort around others. He did report, however, that he exercised and coached a soccer team. The Veteran reported sleeping four hours per night. He stated that he would get up during the night to look around the house and then would walk around the exterior of the home to make sure no one was there. He also checked the doors several times during the day and night. He also reported auditory hallucinations which were described as whispering voices. The examiner noted that the Veteran manifested inappropriate behavior, such as when he would punch walls, throw objects, and break doors in his home. The Veteran denied panic attacks, suicidal and homicidal thoughts. Upon mental status examination, the Veteran's speech was unremarkable, attitude was cooperative, affect was normal, and mood was good. Remote memory was normal, but recent memory was mildly impaired. A GAF score of 60 was provided, indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. The examiner specifically stated that the Veteran's PTSD caused reduced reliability and productivity at work. In April 2014, the Veteran was admitted to the Scott & White Memorial Hospital for stab wounds to the chest as a result of a suicide attempt. Specifically, it was noted that the Veteran had attempted suicide by cutting himself several times in the chest with a pocket knife, which required suture. It was further noted that the Veteran's wife had found him with multiple pre-sternal stab wounds and had brought him to the hospital. The Veteran reported that he had consumed a six pack of beer prior to the event, but did not otherwise recall the actual event. In an April 2014 surgical attending note, Dr. Regner noted that the Veteran had a flat affect and his wife reported that this had been his fourth suicide attempt in the last month. She also reported noticing extreme violence with broken doors at home. She further indicated that the Veteran had mentioned obtaining a gun. According to Dr. Regner, the Veteran's mental stability was "poor." The Veteran was afforded a VA examination in March 2015. During the evaluation, the Veteran reported that he was in a good marriage and had one stepdaughter and two biological children. He reported having a good relationship with his wife and children. The Veteran also reported that he was currently employed as a manger of an auto parts store and as a service writer at a dealership. The examiner noted that the Veteran had symptoms of depressed mood, anxiety, impairment in short and long term memory, and flattened affect. Upon mental status examination, the examiner noted that the Veteran was cooperative during the interview. His speech was within normal limits and he maintained sufficient eye contact during the interview. Psychomotor activity was normal. He appeared euthymic and his affect was within normal limits. His thought process was linear, logical, and goal directed. There were no indications of derailment or any bizarre behavior. His thought content showed no suicidal or homicidal thoughts. There were also no auditory or visual hallucinations. His insight and judgment was adequate. The examiner also noted that the Veteran's PTSD resulted in 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; symptoms controlled by medication. During the November 2015 Board hearing, the Veteran testified that he had been experiencing symptoms of increased avoidance, anger, anxiety, irritability, depression, and sleeplessness since 2009. He also reported episodes of violence, inappropriate behavior, fair impulse control, obsessive and ritualistic behavior, and auditory hallucinations, to include voices whispering since 2009. The Veteran further indicated that since his suicide attempt in 2014 he had been trying to get mental health treatment; however, the Veteran reported feeling very uncomfortable with the assigned mental health provider. J.N. also testified that she had known the Veteran since 2008. She reported that since 2008 the Veteran had manifested period of violence and anger outbursts. J.N. specifically stated that the Veteran has punched numerous holes in walls, beaten a car resulting in broken lights and windows, and has screamed at various individuals. At one point, the Veteran told J.N. that he wanted to kill an individual. The Veteran told J.N. that he "saw it in his head and he had to leave work." Upon review of all the evidence of record, both lay and medical, the Board finds that the evidence is in equipoise as to whether the Veteran's PTSD more nearly approximates a 70 percent disability rating (i.e., occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood) for the entire rating period on appeal. The VA psychiatric examinations and treatment records discussed above reveal that the Veteran's PTSD has been manifested by depression, avoidance, anxiety, anger and irritability with outbursts of violence, sleep impairment, obsessive rituals, auditory hallucinations, homicidal ideation, and a documented suicide attempt. The Board finds that some of these symptoms are specifically included in the 70 percent rating criteria under Diagnostic Code 9411 and more nearly approximate occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. Accordingly, the Board finds that a 70 percent rating for PTSD is warranted for the entire rating period on appeal. The Board further finds that, for the entire rating period on appeal, the Veteran's PTSD does not more nearly approximate the criteria for a 100 percent rating for any period on appeal. The Board finds that the Veteran's PTSD symptoms do not more nearly approximate total social impairment and do not contemplate the symptomology considered under the 100 percent rating criteria. The evidence shows that the Veteran remains married and reported a good relationship with his wife and children. He has also remained employed and reported that he was a manager, which the Board finds indicates some capability to handle stress and manage various responsibilities. In reaching this conclusion regarding the degree of occupational and social impairment, the Board has considered all the Veteran's psychiatric symptoms and impairment, whether or not the symptom is specifically listed in the rating criteria, considering such symptoms as "like or similar to" the symptoms in the rating criteria. See Mauerhan, 16 Vet. App. at 442 (stating that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and that, without those examples, differentiating between rating evaluations would be extremely ambiguous); Vazquez-Claudio, 713 F.3d at 116-17 (the rating criteria under § 4.130 is "symptom-driven" and "a veteran may only qualify for a given disability rating under [this criteria] by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). With this in mind, the evidence shows that the Veteran's overall PTSD picture is already adequately contemplated by the 70 percent rating granted herein. The Veteran does suffer from disturbance of motivation and mood (depression and anxiety), and sleep impairment, but these symptoms are specifically contemplated in the 30 and 50 percent rating criteria. The same is true with the Veteran's suicidal ideation, obsessional rituals which interfere with routine activities (locking doors and checking the perimeter of the house), impaired impulse control (such as unprovoked irritability with periods of violence), difficulty in adapting to stressful circumstances (including work or a work-like setting), and inability to establish and maintain effective relationships, which are symptoms specifically contemplated under the 70 percent PTSD disability rating. In this case, the Veteran was assigned a GAF score of 60 in the August 2009 VA examination. This GAF score reflects moderate symptoms, which the Board finds is consistent with social and occupational deficiencies in areas, such as work, family relations, judgment, thinking, and mood. For these reasons, the Board finds that the evidence of record do not demonstrate total social impairment and do not more nearly approximate the symptoms contemplate under the 100 percent rating criteria. Accordingly, the Board finds that a 70 percent rating for PTSD, but no higher, is warranted for the entire initial rating period on appeal. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's headache disabilities is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's headaches are evaluated by rating criteria contemplating the frequency and severity of the headache attacks and any severe economic inadaptability caused by this disability. Regarding the Veteran's left shoulder, the rating criteria focus on limited range of motion, which the Veteran contends is his primary issue due to pain. The Board has assessed the range of motion of the left shoulder with pain and found the tests consistent with the 10 percent level of disability. The Veteran's PTSD symptoms has been manifested by symptoms such as depression, avoidance, anxiety, anger and irritability with outbursts of violence, sleep impairment, obsessive rituals, auditory hallucinations, homicidal ideation, and a suicide attempt, locking doors and checking the perimeter of the house, difficulty in adapting to stressful circumstances and difficulty regarding relationships. These symptoms are specifically contemplated by the rating criteria. Therefore, the Board finds that the record does not reflect that the Veteran's PTSD disability is so exceptional or unusual as to warrant referral for consideration of the assignment of a higher rating on an extra-schedular basis. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, a comparison of the Veteran's symptoms and functional impairments resulting from his disabilities with the pertinent schedular criteria does not show that his service-connected headache or cervical spine disabilities at issue present "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). The functional limitations imposed by the Veteran's disabilities are specifically contemplated by the criteria discussed above, including the effect of the Veteran's headache and cervical spine pain on his occupation and daily life. In the absence of exceptional factors associated with the headache disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Further, according to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the Veteran has reported that he is working as an assistant welder for 30-40 hours a week for the past 2 years. See June 2015 VA TBI examination report. The Veteran also reported working as a truck driver during the November 2015 Board hearing. See Board Hearing Transcript at pg. 14. Moreover, the Veteran has not specifically raised the issue of unemployability. As such, the Board finds that the issue of TDIU is not raised at this time. ORDER A 30 percent rating for headaches is granted, subject to regulations governing the payment of monetary awards. For the rating period prior to September 1, 2011, a 10 percent rating for residuals of a left shoulder injury is granted, subject to regulations governing the payment of monetary awards. For the rating period beginning September 1, 2011, a rating in excess of 10 percent for residuals of a left shoulder injury is denied. For the entire initial rating period, a 70 percent rating for PTSD is granted, subject to regulations governing the payment of monetary awards. (CONTINUED ON NEXT PAGE) REMAND The Veteran currently receives a 10 percent schedular rating for memory impairment as a result of his TBI under 4.124a, Diagnostic Code 8045, effective June 17, 2009. The Veteran contends that a rating in excess of 10 is warranted. The criteria for Diagnostic Code 8045 effective from October 23, 2008 provide that there are three main areas of dysfunction that may result from a traumatic brain injury and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral dysfunction, and physical (including neurological). Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2015). The Board notes that various disabilities and symptoms associated with the Veteran's TBI have already been service connected. Specifically, the Veteran's emotional and psychiatric symptoms have already been considered in his service-connected PTSD disability. Further, the Veteran has also been granted service connection for headaches, tinnitus, and hearing loss. As noted above, the RO has also granted a 10 percent rating for memory impairment as a result of the Veteran's TBI. However, the Veteran has also maintained that he has vertigo as a result of his TBI. The Veteran has consistently complained of symptoms of dizziness and loss of balance and has been diagnosed with benign paroxysmal positional vertigo. See June and July 2015 VA examination. Under Diagnostic Code 8045, and specifically for physical dysfunction (including balance problems), evaluations are based under an appropriate diagnostic code for the particular dysfunction. See 38 C.F.R. § 4.124a. In this case the Veteran's benign paroxysmal positional vertigo is evaluated under Diagnostic Code 6204, which provides ratings based on peripheral vestibular disorders. Under this code, a 10 percent rating is assigned for peripheral vestibular disorder manifested by occasional dizziness. A maximum 30 percent rating is assigned for peripheral vestibular disorder manifested by dizziness and occasional staggering. See 38 C.F.R. § 4.87, Diagnostic Code 6204 (2015). A Note to Diagnostic Code 6204 provides that objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this Diagnostic Code. Id. In a June 2015 VA ENT examination, the Veteran was diagnosed with benign paroxysmal positional vertigo. However, under the section listed as "Dix Hallpike test (Nylen-Barany test) for vertigo" the response indicated was "Exam using this test not indicated." The Board finds this statement unclear. The remaining evidence of record does not indicate any objective findings supporting a diagnosis of vestibular disequilibrium as required for a compensable rating under Diagnostic Code 6204. As such, the Board finds that the evidence of record is unclear as to whether the Veteran has objective findings supporting a diagnosis of vestibular disequilibrium as required for a separate, compensable rating. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an appropriate VA examination. The examiner is asked to perform all appropriate testing. The examiner should note that the Veteran has been diagnosed with benign paroxysmal positional vertigo. The examiner is then asked to provide an opinion as to whether or not there are objective findings supporting a diagnosis of vestibular disequilibrium. See 38 C.F.R. § 4.87, Diagnostic Code 6204 (2015). The examiner should also indicate whether the disorder is manifested by occasional dizziness or dizziness and occasional staggering In addressing the questions above the examiner must consider the Veteran's symptoms, in addition to the results of all objective testing performed. The examination report must include a complete rationale for the opinion expressed. 2. Thereafter, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case and afford them a reasonable opportunity to respond. Then return the case to the Board for further appellate review, if otherwise in order. 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). 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). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs