Citation Nr: 1804194 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 06-16 048 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased rating for hypertensive cardiovascular disease, currently rated 30 percent disabling prior to September 6, 2016 and 60 percent disabling from September 6, 2016. 2. Entitlement to an increased rating for hypertension, currently rated 10 percent disabling. 3. Entitlement to an increased rating for anxiety reaction with dizziness and dysthymia, rated 30 percent disabling prior to April 18, 2011, 50 percent disabling from April 18, 2011, 30 percent disabling from May 28, 2013, and 50 percent disabling from September 6, 2016. 4. Entitlement to an increased rating for tension headaches, currently rated 30 percent disabling. 5. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to April 18, 2011 and from May 28, 2013. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran served on active military duty from May 1968 to April 1970. These matters come to the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision by the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2009, the RO granted a TDIU from April 18, 2011 to May 28, 2013; however, since the benefit was not granted for the entire pendency of the appeal, the issue remained before the Board for adjudication. In a July 2010 decision, the Board denied claims for increased ratings for anxiety reaction with headaches, dizziness, and dysthymia; hypertensive cardiovascular disease; and hypertension. The Board also remanded the claim for a TDIU. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). Based on a Joint Motion for Remand (JMR), in February 2011, the Court remanded that Board decision for development in compliance with the JMR. In October 2011, pursuant to the JMR, the Board remanded the claims for increased ratings for anxiety reaction with headaches, dizziness, and dysthymia; hypertensive cardiovascular disease; and hypertension for additional development. In September 2015, the RO granted a separate 30 percent rating for tension headaches effective June 20, 2013 and, accordingly, that issue is before the Board for adjudication as part and parcel of the original claim for an increased rating for anxiety reaction. In a June 2016 decision, the Board granted a 30 percent rating for tension headaches from March 1, 2005 but denied a rating in excess of 30 percent from June 20, 2013. The Veteran appealed that decision to the Court. Pursuant to a JMR, in February 2011, the Court remanded that Board decision for development in compliance with the JMR. In September 2016, the RO increased the rating for hypertensive cardiovascular disease to 60 percent disabling and increased the rating for anxiety reaction with dizziness and dysthymia to 50 percent disabling, both effective September 6, 2016. The issue of entitlement to a TDIU prior to April 18, 2011 and from May 28, 2013 is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to September 6, 2016, the Veteran's hypertensive cardiovascular disease had not been manifested by more than one episode of acute congestive heart failure in the past year; or workload greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 2. From September 6, 2016, the Veteran's hypertensive cardiovascular disease has not been manifested by chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 3. The Veteran's hypertension has not been manifested by diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 4. Prior to April 18, 2011, the Veteran's anxiety reaction with dizziness and dysthymia had not been manifested by occupational and social impairment with reduced reliability and productivity. 5. From April 18, 2011 to May 27, 2013, the Veteran's anxiety reaction with dizziness and dysthymia had been manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 6. From May 28, 2013 to September 5, 2016, the Veteran's anxiety reaction with dizziness and dysthymia had been manifested by occupational and social impairment with reduced reliability and productivity. 7. From September 6, 2016, the Veteran's anxiety reaction with dizziness and dysthymia has not been manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 8. Prior to December 19, 2010, the Veteran's tension headaches had not been manifested by very frequent completely prostrating prolonged attacks productive of severe economic inadaptability. 9. From December 19, 2010, the Veteran's tension headaches have been manifested by very frequent completely prostrating prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for an increased rating for hypertensive cardiovascular disease, currently rated 30 percent disabling prior to September 6, 2016 and 60 percent disabling from September 6, 2016, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.104, Diagnostic Code 7007 (2017). 2. The criteria for an increased rating for hypertension, currently rated 10 percent disabling, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.104, Diagnostic Code 7101 (2017). 3. The criteria for an increased rating for anxiety reaction with dizziness and dysthymia, rated 30 percent disabling prior to April 18, 2011, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.130, Diagnostic Code 9433 (2017). 4. Resolving the benefit of the doubt in the Veteran's favor, the criteria for an increased rating of 70 percent, but not higher, for anxiety reaction with dizziness and dysthymia from April 18, 2011 to May 27, 2013, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.130, Diagnostic Code 9433 (2017). 5. Resolving the benefit of the doubt in the Veteran's favor, the criteria for an increased rating of 50 percent, but not higher, from May 28, 2013 to September 5, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.130, Diagnostic Code 9433 (2017). 6. The criteria for an increased rating for anxiety reaction with dizziness and dysthymia, rated 50 percent disabling from September 6, 2016, have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.3, 4.130, Diagnostic Code 9433 (2017). 7. The criteria for an increased rating for tension headaches, currently rated 30 percent disabling prior to December 19, 2010, have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.3, 4.27, 4.124a, Diagnostic Code 8199-8100 (2017). 8. Resolving the benefit of the doubt in the Veteran's favor, the criteria for the maximum 50 percent rating for tension headaches from December 19, 2010 have been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.3, 4.27, 4.124a, Diagnostic Code 8199-8100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In this case, VA provided the Veteran with 38 U.S.C. § 5103(a)-compliant notice in March 2005 and February 2011. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claim, including with respect to VA examination of the Veteran. Neither the Veteran nor his representative has identified any deficiency in VA's notice or assistance duties. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The Board has been directed to consider only those factors contained wholly in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). However, the Board has been advised to consider factors outside the specific rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The terms mild, moderate, and severe are not defined in the Rating Schedule. Rather than applying a mechanical formula, all of the evidence must be evaluated to the end that all decisions are equitable and just. 38 C.F.R. § 4.6 (2017). Use of such descriptive terms by medical examiners, although an element of the evidence to be considered, is not dispositive of an issue. Such evidence must be interpreted in light of the whole recorded history, reconciling the evidence into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2017). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When the Veteran is requesting an increased rating for a service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. Powell v. West, 13 Vet. App. 31 (1999). Nevertheless, the Board acknowledges that the Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis below is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. In this case, VA received the Veteran's claim for an increased rating for his disabilities in March 2005. Hypertensive Cardiovascular Disease The Veteran's hypertensive cardiovascular disease is rated at 30 percent prior to September 6, 2016 and 60 percent from September 6, 2016 under Diagnostic Code 7007. 38 C.F.R. § 4.104 (2017). Under that code, chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent warrants a 100 percent rating. More than one episode of acute congestive heart failure in the past year; or workload greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent warrants a 60 percent rating. At an April 2005 VA examination, the Veteran reported a history of hypertension since 1970 and being on medication since 1984. The examiner noted that the Veteran does not have a history of congestive heart failure, his ejection fraction in June 2001 was normal at 53 percent, and x-rays have not shown congestive heart failure. The examiner estimated the Veteran's workload at 5-7 METs. At a March 2011 VA examination, the Veteran reported a longstanding history of hypertension. The examiner noted that the Veteran does not have a history of myocardial infarction or findings of congestive heart failure or hospitalizations for such or chronic congestive heart failure. The examiner noted that the Veteran has been evaluated in the past for atypical chest pain which was not felt to be angina, and his problems include being extremely overweight, chronic venous insufficiency of the lower legs, and previous deep venous thrombosis with pulmonary embolus related to coagulopathy. The examiner noted that a January 2011 echocardiogram showed a normal left ventricle and an estimated ejection fraction of 55 percent. The examiner estimated the Veteran's workload at at least 5-7 METs. With no other relevant records dated during this time period, the Board finds that prior to September 6, 2016, the Veteran's hypertensive cardiovascular disease had not been manifested by more than one episode of acute congestive heart failure in the past year; or workload greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The evidence simply does not support such findings. Thus, an increased rating for hypertensive cardiovascular disease, currently rated 30 percent disabling prior to September 6, 2016, is not warranted. At a September 6, 2016 VA examination, the Veteran denied requiring continuous medication for control of his heart condition, and denied a history of myocardial infarction, congestive heart failure, cardiac arrhythmia, a heart valve condition, any infectious cardiac conditions, and pericardial adhesions. Based on an interview-based METs test, the examiner estimated the Veteran's workload to be from 1-3 METs. However, the examiner noted that the Veteran was morbidly obese and that obesity was the most significant cause for his dyspnea and fatigue with exertion. The examiner noted that the Veteran has atypical chest pain which has been called angina but cardiac workup in the past has been limited due to his morbid obesity and therefore to say that this symptom is due to hypertensive heart disease would require speculation. The examiner noted that the Veteran's METs is also limited by his severe venous stasis disease but essential hypertension is not a cause of that disease. The examiner noted that the Veteran has prior deep venous thrombosis but essential hypertension is not a cause of that disease. The examiner stated that the Veteran's cardiac METs is based on the echocardiogram which shows normal left ventricle size and systolic function with no congestive heart failure and an ejection fraction of 50 to 55 percent. The examiner concluded that based on this, the Veteran's cardiac METs would be at least 7 to 10. Again, with no other relevant records dated during this time period, the Board finds that the Veteran's hypertensive cardiovascular disease has not been manifested by chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. The evidence simply does not support such findings. Thus, an increased rating for hypertensive cardiovascular disease, currently rated 60 percent disabling from September 6, 2016, is not warranted. In conclusion, an increased rating for hypertensive cardiovascular disease is not warranted at any time during the rating period. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hypertension The Veteran's hypertension is rated at 10 percent under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under that code, a maximum 60 percent rating is warranted for diastolic pressure predominantly 130 or more; a 40 percent is warranted for diastolic pressure predominantly 120 or more; and a 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. After review, the Board finds that the Veteran's hypertension has not been manifested by diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. The medical records show that his blood pressure has been well below 200/110. At an April 2005 VA examination, his blood pressure readings were 150/90, 150/80, and 150/80. At a March 2011 VA examination, his blood pressure readings were 150/72, 146/70, and 150/74. At a September 2016 VA examination, his blood pressure readings were 153/66, 154/74, and 147/66. VA medical records show diastolic pressure readings as high as the 70s and systolic pressure readings as high as the 170s, except for one reading in the 180s during a visit to the emergency room for other reasons. Thus, a rating in excess of 10 percent is not warranted. In conclusion, an increased rating for hypertension, currently rated 10 percent disabling, is not warranted at any time during the rating period. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Anxiety Reaction The Veteran's anxiety reaction with dizziness and dysthymia is rated at 30 percent prior to April 18, 2011, 50 percent from April 18, 2011, 30 percent from May 28, 2013, and 50 percent from September 6, 2016. The disability is rated under Diagnostic Code 9433 for persistent depressive disorder (dysthymia). 38 C.F.R. § 4.130 (2017). Under that code, a 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent rating is warranted 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; difficulty in establishing and maintaining effective work and social relationships. Prior to April 18, 2011 At an April 2005 VA examination, the Veteran reported a depressed mood, irritability, insomnia, feeling of helplessness and hopelessness, and difficulty with concentration, and noted that these symptoms were moderate. He reported being married to his wife since 1968 and having two children and two step-children. He reported starting part-time work as a school bus monitor within the last month. Examination revealed that he was anxious with a sad mood, restricted affect, and slow and hesitant speech. Thought processes were goal-directed and coherent. There were no delusions, hallucinations, suicidal ideations, or obsessions or compulsions. Memory was intact but there was difficulty with delayed recall. Insight was poor. Judgment was intact. The examiner provided a diagnosis of dysthymic disorder, estimated the GAF score at 51, and indicated that the score reflects moderate impairment in social and industrial functioning. Given the above, the record fails to show that the Veteran's anxiety reaction with dizziness and dysthymia had resulted in reduced reliability and productivity, or in any of the symptoms indicative of a higher 50 percent rating. The record only shows that his disability had resulted in depressed mood, anxiety, chronic sleep impairment, and mild memory loss. The Board notes that these are symptoms of the currently assigned 30 percent rating. While the examiner indicated that the Veteran's disability was moderate in severity, the Board observes that this is reasonably contemplated by the current 30 percent rating. A review of the VA medical records also fails to show that the Veteran's disability warranted a rating in excess of 30 percent. While a January 2011 record indicates that his symptoms had worsened since he quit his part-time job in December due to physical health problems, the record does not show a level of occupational and social impairment, or signs and symptoms, that supports a higher rating. While the examiner noted that the Veteran had mild paranoia, with the belief that people were listening to his telephone conversations, his presentation otherwise did not indicate a higher rating. While that record reflects the psychologist's assessment that the Veteran's symptoms were moderate to severe and resulted in a GAF score of 48, they are not supported by the noted symptoms. Further, a February 2011 record shows the psychologist's assessment that the Veteran was improved and almost back to baseline. While persistent delusions are a symptom of a 100 percent rating, the totality of the evidence does not show that the Veteran's disability met the criteria for a 100 percent rating. There is no objective evidence that his disability resulted in total occupational and social impairment or that he had any of the other symptoms of a 100 percent rating. Accordingly, the Board finds that the Veteran's anxiety reaction with dizziness and dysthymia had not been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Thus, a rating in excess of 30 percent prior to April 18, 2011 is not warranted. From April 18, 2011 At an April 18, 2011 VA examination, the Veteran reported not doing well lately. He reported sleep impairment, poor motivation, impaired memory, anxiety, and irritability. He denied suicidal ideation, panic attacks, and impaired impulse control. He reported quitting his part-time job as a school bus monitor in October 2010 due to the stress of dealing with children. He reported being married for 42 years, that his marriage was stable, and that he was close to his daughter, with no mention of his relationship with his son. He reported being estranged from his family and he does not trust people, including his siblings. Examination revealed a sad affect congruent to mood, no delusions or hallucinations, normal thought processes, and intact memory. The examiner estimated the GAF score at 50 and indicated that the score reflects moderate impairment in psychosocial functioning. The examiner stated that the Veteran's current symptoms make him unemployable and that the Veteran's social life has been significantly compromised, noting that although he is married and close to his wife he has minimal interpersonal social interaction including being estranged from his siblings and he becomes anxious and nervous around people. Given the above, the Veteran's anxiety reaction with dizziness and dysthymia had resulted in occupational and social impairment with deficiencies in work and family relations, but not in judgment, thinking, or mood. As for symptoms, that he quit his part-time job due to the stress of dealing with children indicates difficulty in adapting to stressful circumstances. However, he did not endorse any of the other symptoms indicative of occupational and social impairment with deficiencies in most areas. While the examiner indicated that the Veteran had moderate symptoms, his assessment was that the Veteran was unemployable and had significant social impairment. Resolving the benefit of the doubt in the Veteran's favor, the Board finds that his anxiety reaction with dizziness and dysthymia had been manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Thus, a higher 70 percent rating from April 18, 2011 to May 27, 2013 is warranted. However, an even higher 100 percent rating is not warranted. While the Veteran may have had total occupational impairment at that time, he did not have total social impairment, which is also required for a 100 percent rating. He was in a stable marriage and close to one on his children. Thus, while he did not have a good relationship with his siblings, he had a good relationship with his wife and daughter. He also did not have any of the symptoms indicative of a 100 percent rating. Thus, the Board finds that the Veteran's anxiety reaction with dizziness and dysthymia had not been manifested by total occupational and social impairment. From May 28, 2013 At a May 28, 2013 VA examination, the Veteran reported a depressed mood, suspiciousness, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He reported that his marriage was better than it has been, that his relationship with his daughter was mostly limited to phone calls due to long distance and that he sees his son every now and then but their visits were limited due to being a truck driver. The examiner estimated the GAF score at 55. The examiner stated that the Veteran's psychiatric disability results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. Given the above, the Veteran's anxiety reaction has been manifested by flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board appreciates the examiner's assessment that the Veteran's disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which supports a 30 percent rating. However, based on the Veteran's symptoms and resolving the benefit of the doubt in his favor, the Board finds that his anxiety reaction with dizziness and dysthymia had been manifested by occupational and social impairment with reduced reliability and productivity. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Thus, a higher 50 percent rating from May 28, 2013 to September 5, 2016 is warranted. However, an even higher 70 percent rating is not warranted as the Veteran's anxiety reaction with dizziness and dysthymia had not resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The examiner's assessment was that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Also, the Veteran did not report suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or inability to establish and maintain effective relationships. From September 6, 2016 At a September 6, 2016 VA examination, the Veteran reported depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. He noted that he does not like being around people other than his wife and sister, and that he does not have any friends, but that he has always been a loner. He also reported visual hallucinations such as seeing a bullet hole in a table cloth or seeing inanimate objects. Examination revealed that the Veteran was oriented with euthymic mood with congruent affect, alert, cooperative, tracked conversation well, had concrete thought processes with thought content focused on responding to questions, good eye contact, speech of normal rate/volume, motoric movements within normal limits, and denied hallucinations. The examiner stated that the Veteran's psychiatric disability results in occupational and social impairment with reduced reliability and productivity. With no other relevant records dated since September 6, 2016, the Board finds that the Veteran's anxiety reaction with dizziness and dysthymia has not been manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The examiner's assessment does not support such a finding. While the Veteran reported difficulty in adapting to stressful circumstances, the totality of the examination findings, along with the examiner's overall assessment, does not support a finding that his psychiatric disability results in occupational and social impairment with deficiencies in most areas. Thus, a 70 percent rating is not warranted. While the Veteran reported a history of visual hallucinations, there is no indication that they are persistent, denying them at the time of the examination, or result in total occupational and social impairment in combination with his other symptoms. Thus, a 100 percent rating is not warranted. Given the above, a rating in excess of 50 percent from September 6, 2016 is not warranted. In conclusion, the Board has resolved the benefit of the doubt in the Veteran's favor in granting an increased 70 percent rating for anxiety reaction with dizziness and dysthymia from April 18, 2011 to May 27, 2013 and an increased 50 percent rating from May 28, 2013 to September 5, 2016; however, as the preponderance of the evidence is against an even higher rating during those times or an increased rating at any other time during the rating period, those aspects of the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Tension Headaches A separate 30 percent rating for the Veteran's tension headaches has been assigned effective March 1, 2005. The disability is rated under Diagnostic Code 8199-8100. 38 C.F.R. § 4.124a (2017). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27 (2017). Here, the hyphenated diagnostic code indicates that the Veteran's tension headaches are rated by analogy under the criteria for migraines under Diagnostic Code 8100. Under this diagnostic code, a 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months, and a maximum 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. On a claim for increase received in March 2005, the Veteran reported that he had been experiencing headaches more frequently in the past year and that they were more severe with physical exertion, noting that digging or chopping wood for a minute will cause a severe headache. The report of an April 2005 VA mental examination shows that the Veteran has not been employed full-time since 1984 due to various health problems listed as gout, hypertension, a pulmonary embolism, pulmonary hypertension, gastroesophageal reflux disease, angina, and sleep apnea. He reported working part-time as a school bus monitor, and that he can perform basic and industrial activities of daily living without difficulty. He did not report headaches during the examination or during a VA examination for aid and attendance benefits that same day. On his October 2005 notice of disagreement, the Veteran indicated that he was a school bus monitor and that he develops a headache as soon as he gets on the bus and is mentally and physically exhausted at the end of the day. In correspondence dated March 2006, the Veteran reported that his medications cause serious headaches. On an April 2011 claim for a TDIU, the Veteran indicated that his nerves and heart condition prevent him from securing or following a substantially gainful occupation and that he worked 20 hours part-time from 2004 to December 18, 2010, losing one month of work due to illness during that time. At a December 2011 VA examination, the Veteran reported constant headaches that were not relieved by medication. The examiner noted a history of mild headaches, sometimes with mild dizzy spells. The Veteran described his headaches as a dull aching and bifrontal in location without nausea or phono or photophobia. He stated that his headaches could occur at any time of the day, last up to one-half of the day, and recur three to four times a week. As he had not worked in the prior 6 months, he had not missed work due to headaches but he estimated that he had had 30 or more incapacitating headaches. The examiner found that the Veteran did not have characteristic prostrating attacks of migraine or non-migraine headache pain. In the remarks section, the examiner noted the Veteran's history of tension headaches recurring two to three times a week with prostrating attacks several times a month. However, the examiner found that the Veteran's reported history was not supported by the medical records. The examiner indicated that the Veteran's headache condition did not impact his ability to work. Based on the medical records, the examiner found that the Veteran's headaches would not prevent employment. The Veteran underwent another VA examination in June 2013 that was conducted by the same examiner. The examiner indicated that there had been no mention of headaches in the VA treatment records since the December 2011 VA examination. The examiner also noted that the Veteran was not being treated for headaches. The Veteran described his headaches as a dull aching and bifrontal in location without nausea or phono or photophobia. He stated that the headaches could occur at any time of day, with episodes lasting up to an entire day, and recurred two to four times a week. He noted that the headaches have awakened him from sleep. He stated that he took Lortab for the headaches; however, the examiner noted that this medication was prescribed for back pain. As the Veteran had not worked in the prior 6 months, he did not miss time from work due to headaches but estimated that he had had 40 to 50 or more incapacitating headaches. The examiner found that the Veteran had very frequent prostrating and prolonged attacks of non-migraine pain. In the remarks section, the examiner noted a history of tension headaches recurring two to three times a week with prostrating attacks several times a month. However, the examiner again found that the Veteran's reported history was not supported by the medical records. Based on the medical records, the examiner found that the Veteran's headaches would not prevent employment. While the Veteran's claims file contains numerous VA treatment records, only a few records mention his headaches. A January 2006 record shows complaints of headaches and dizziness. February 2007 records reflect chronic headaches. While October 2008 records show complaints of throbbing left-sided headaches, those complaints appear to be associated with an eye condition. January 2015 records show complaint of headaches two to three times per week treated with over-the-counter medication. An October 2015 record shows complaints of headaches. On a January 2017 claim for a TDIU, the Veteran indicated that his heart condition, headaches, hypertension, and anxiety prevent him from securing or following a substantially gainful occupation, reiterating that he worked 20 hours part-time from 2004 to 2010, losing one month of work due to illness during that time. Given the above, while the objective evidence does not indicate that the Veteran's tension headaches have resulted in very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability, his subjective reports indicate that they have. The Veteran essentially reported very frequent prostrating and prolonged attacks of headache pain during both VA examinations, having had 30 or more such attacks in the past six months at the December 2011 examination and 40 or more at the June 2013 examination. In that regard, in the June 2016 decision, the Board essentially found credible the Veteran's reports of the frequency and severity of his headaches in awarding an earlier effective date for the separate rating for tension headaches. Resolving the benefit of the doubt in the Veteran's favor, the Board finds that his tension headaches have resulted in very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Thus, the maximum 50 percent rating is warranted for the Veteran's tension headaches. The remaining question is when the Veteran's tension headaches started being manifested by very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. In answering this question, the Board looks to his claims for a TDIU. The Veteran's April 2011 claim for a TDIU shows that he worked part-time as a school bus monitor from 2004 to December 18, 2010, that he worked 20 hours per week during that time, and that he lost one month of work due to illness during that time. At the April 2005 VA examination, the indicated that he began that part-time work in March 2005, which would indicate that he worked for close to six years. While he did not specify that his headaches were the cause of any of those lost days, as the claim specified that his anxiety reaction contributed to his inability to secure or follow a substantially gainful occupation, and the tension headaches were still associated with his anxiety reaction at that time, the record indicates that his tension headaches resulted in some of those lost days. His January 2017 claim for a TDIU specified that his headaches contributed to his inability to secure or follow a substantially gainful occupation and so supports that finding. However, missing one month of work in close to six years does not indicate severe economic inadaptability, especially as not all of those lost days have been attributed to the headaches. While his October 2005 notice of disagreement indicates that he developed a headache as soon as he boarded the bus, he was able to finish his shift. The medical evidence also fails to show that his tension headaches significantly affected his ability to work. A September 2005 VA treatment record shows that he worked a few hours in the morning and afternoon, with no mention of tension headaches. A March 2006 VA treatment record shows that he continued to work part-time and was tolerating the physical and emotional demands of the job, again with no mention of tension headaches. Thus, the record shows that during the time he was working part-time, his tension headaches were not productive of severe economic inadaptability. However, the Veteran was eventually unable to continue that part-time work due in part to his headaches. While an inability to secure or follow a substantially gainful occupation is not required to show that his tension headaches were productive of severe economic inadaptability, it is one indicator and in this case one that provides an objective date, December 18, 2010, the last day that the Veteran worked part-time. Resolving the benefit of the doubt in the Veteran's favor, the Board finds that his tension headaches started being manifested by very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability on December 19, 2010, the day after he last worked. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Accordingly, an increased 50 percent rating for tension headaches is warranted from December 19, 2010. However, as discussed, there is no objective evidence that shows that his tension headaches were of such severity prior to that time to warrant a rating in excess of 30 percent prior to December 19, 2010. In conclusion, the Board has resolved the benefit of the doubt in the Veteran's favor in granting an increased 50 percent rating for tension headaches from December 19, 2010; however, as the preponderance of the evidence is against an increased rating at any other time during the rating period, that aspect of the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. ORDER An increased rating for hypertensive cardiovascular disease, currently rated 30 percent disabling prior to September 6, 2016 and 60 percent disabling from September 6, 2016, is denied. An increased rating for hypertension, currently rated 10 percent disabling, is denied. An increased rating for anxiety reaction with dizziness and dysthymia, rated 30 percent disabling prior to April 18, 2011, is denied. An increased rating of 70 percent for anxiety reaction with dizziness and dysthymia from April 18, 2011 to May 27, 2013 is granted, subject to the provisions governing the award of monetary benefits. An increased rating of 50 percent for anxiety reaction with dizziness and dysthymia from May 28, 2013 to September 5, 2016 is granted, subject to the provisions governing the award of monetary benefits. An increased rating for anxiety reaction with dizziness and dysthymia, rated 50 percent disabling from September 6, 2016, is denied. An increased rating for tension headaches, currently rated 30 percent disabling prior to December 19, 2010, is denied. An increased rating of 50 percent for tension headaches from December 19, 2010 is granted, subject to the provisions governing the award of monetary benefits. REMAND In light of the Board's grants of partial increased ratings for anxiety reaction and tension headaches, the AOJ should readjudicate the claim for a TDIU prior to April 18, 2011 and from May 28, 2013. Accordingly, the case is REMANDED for the following actions: Readjudicate the claim for a TDIU in light of the Board's grants of partial increased ratings for anxiety reaction and tension headaches. If any decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters 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. §§ 5109B, 7112 (2012). ____________________________________________ KELLI A. KORDICH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs