Citation Nr: 1806028 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 12-19 334 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a depressive disorder as secondary to service-connected disability. 2. Entitlement to service connection for an anxiety disorder as secondary to service-connected disability. 3. Entitlement to service connection for hypertension as secondary to service-connected disability. 4. Entitlement to an initial compensable evaluation for service-connected residuals of traumatic brain injury. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T.S.E., Counsel INTRODUCTION The Appellant served on active duty from February 1968 to November 1969. This matter comes before the Board of Appellants' Appeals (Board) on appeal from rating decisions of the Cleveland, Ohio, Department of Appellants Affairs (VA) Regional Office (RO). In June 2011, the RO denied claims of service connection for an anxiety disorder, a depressive disorder, and hypertension. In August 2011, the RO granted service connection for residuals of a traumatic brain injury, evaluated as noncompensable. In his appeal (VA Form 9), received in July 2012, the Veteran indicated that he desired a videoconference hearing before a Veterans Law Judge. In August 2017, he was notified that he had been scheduled for a hearing in October 2017. However, in October 2017, he stated that he was not coming to his hearing, and requested that his claims be adjudicated. See report of general information (VA Form 27-0820), dated in October 2017. The Veteran's request for a Board hearing is therefore considered withdrawn, and the Board will proceed with adjudication at this time. 38 C.F.R. § 20.702 (d) (2017). FINDINGS OF FACT 1. In October 2012, the RO granted service connection for posttraumatic stress disorder; in November 2014, the RO recharacterized this service-connected disability as "other specified trauma and stressor related disorder"; in January 2017, the RO recharacterized this service-connected disability as "other specified depressive disorder with other specified trauma and stressor related disorder." 2. The weight of the evidence is against a finding that the Veteran has an anxiety disorder, or hypertension that were caused or aggravated by a service-connected disability. 3. Prior to March 16, 2016, the Veteran's residuals of a traumatic brain injury are not shown to have been productive of symptoms warranting more than a level "0" in any category under Diagnostic Code (DC) 8045. 4. As of March 16, 2016, and no earlier, the Veteran's residuals of a traumatic brain injury are shown to have been productive of mild impairment of visual spatial orientation, but not symptoms warranting more than a level "1" in any category under DC 8045. CONCLUSIONS OF LAW 1. The claim for service connection for a depressive disorder is moot, and is dismissed. 38 U.S.C. § 7104 (2014); 38 C.F.R. § 20.101 (2017). 2. The criteria for service connection for an anxiety disorder and hypertension have not been met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. § 3.102, 3.159, 3.310 (2017). 3. Prior to March 16, 2016, the criteria for an initial compensable evaluation for service-connected residuals of a traumatic brain injury have not been met. 38 U.S.C. §§ 1155, 5107(b) (2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8045 (2017). 4. As of March 16, 2016, and no earlier, the criteria for a 10 percent evaluation, and no higher, for service-connected residuals of a traumatic brain injury, have been met. 38 U.S.C. §§ 1155, 5107(b) (2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8045 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Dismissal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. In February 2002, the RO denied the claim for depression on a direct basis. In July 2010, the Veteran filed to reopen his claim for depression. In June 2011, the RO denied the claim. The Veteran appealed. In October 2012, the RO granted service connection for posttraumatic stress disorder. In November 2014, the RO recharacterized this service-connected disability as "other specified trauma and stressor related disorder." In January 2017, the RO recharacterized this service-connected disability as "other specified depressive disorder with other specified trauma and stressor related disorder." The RO's January 2017 grant of service connection for a depressive disorder constitutes a full award of the benefit sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). There remains no claim over which the Board may exercise appellate jurisdiction. Id.; 38 U.S.C. §§ 7104, 7105. The claim for service connection for a depressive disorder must therefore be dismissed as moot. Service Connection The Veteran asserts that he is entitled to service connection for an anxiety disorder, and hypertension, as secondary to service-connected disability. Specifically, he has argued that he has both of these disabilities due to his service-connected other specified depressive disorder with other specified trauma-and stressor related disorder. As an initial matter, when determining service connection, all theories of entitlement, direct and secondary, must be considered by the Board if raised by the evidence of record, applying all relevant laws and regulations. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). In this case, the Veteran does not assert, and there is no evidence to show, that he has anxiety disorder, or hypertension, as directly related to active service. The Veteran's service treatment reports, to include a separation examination report dated in November 1969, do not show any relevant complaints, findings, or diagnoses. There is also no evidence to show that the Veteran had hypertension within one year of separation from service. Although the Veteran served in Vietnam and is presumed to have been exposed to Agent Orange, neither of the claimed conditions are presumed as due to exposure to Agent Orange, nor is there any competent evidence linking either hypertension or an anxiety disorder to exposure to Agent Orange. See 38 U.S.C. § 1116(f) (2014): 38 C.F.R. §§ 3.307, 3.309 (2017); Combee v. Brown, 34 F.3d 1039, 1043 (Fed.Cir. 1994). Accordingly, the claims will not be analyzed on a direct or presumptive basis, or as due to exposure to Agent Orange. Service connection may be granted on a secondary basis, for a disability that is proximately due to, or the result of, an established service-connected disorder. 38 C.F.R. § 3.310. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310 (b). In this case, service connection is currently in effect for: coronary artery disease, "other specified depressive disorder with other specified trauma-and stressor related disorder," scar, residuals of gunshot wound to the occipital area, atypical migraine headaches with dizziness, tinnitus, bilateral hearing loss, and residuals of traumatic brain injury. The post-service medical evidence includes an initial psychiatric evaluation from S.R., M.D., dated in October 2000, which notes that the Veteran had "expressed some depression and anxiety problems" a couple of weeks earlier. He was noted to be having difficulties at his job following a back injury. On examination, there was some anxiety, and depressive symptoms of a dysthymic nature. It was noted that he did not have hypertension. The diagnostic impression was dysthymic disorder with anxiety. He was recommended to begin taking Celexa. A November 2000 report notes the addition of Wellbutrin. A June 2001 report notes that he was about to begin chemotherapy for breast cancer, and that he was taking Wellbutrin and Trazodone. Reports from the Cleveland Clinic, dated in May 2001, note a medical history that includes hypertension. VA progress notes, dated in 2005, shows treatment for inter alia PTSD, and depression. VA progress notes, dated in 2007, contain multiple notations of chronic depression with anxiety, to include a history of anxiety attacks. In each case, the diagnoses involved depression, i.e, depression, major depression, or major depressive disorder. A VA hypertension examination report, dated in December 2010, shows that the Veteran's claims file had been reviewed. The examination report noted that hypertension had not been diagnosed. The Veteran reported that he had never been diagnosed with hypertension. There was no treatment for hypertension. Medications were not required for control of the Veteran's blood pressure. In 2010, the Veteran's blood pressure was noted to range from 108 to 113 (systolic) and from 62 to 80 (diastolic). There was no hypertensive heart disease. The "diagnosis" was "normal blood pressure." A VA examination report, dated in December 2010, shows that the Veteran had been diagnosed with major depressive disorder and PTSD. He was afforded psychological testing. On the Beck Anxiety Inventory he scored in the severe range of anxiety symptoms. The report notes that these measures were highly face-valid and based solely on self-report. The examiner stated, "As a result of the invalid nature of his results on the MMPI-2 (Minnesota Multiphasic Personality Inventory-2), and on a recent administration of the MMPI-2 (10/26/10) which yielded similar results, this calls into question the validity of the Veteran's self-report of symptoms in this evaluation." The Axis I diagnosis was depressive disorder NOS (not otherwise specified). The examiner noted that the Veteran had been evaluated in December 2010, see supra, and it had been determined that he did not have hypertension. Therefore, the examiner could not provide an opinion as to whether or not the Veteran had hypertension that was etiologically related to his service-connected psychiatric disorder. The examiner concluded that there was not sufficient evidence to support a diagnosis of anxiety. She explained that his primary focus of symptoms related to complaints of subjective depression, and that there was a history of concerns with depression, but that there was minimal mention of anxiety complaints, with no formal diagnosis of anxiety. She noted that on current examination there was evidence of symptom exaggeration that made it impossible to accurately diagnose the presence of an anxiety disorder without resorting to mere speculation. The examiner stated that the Veteran's presentation appeared consistent with compensation-seeking behaviors. She stressed that she was not concluding that the Veteran was not experiencing symptoms of anxiety. In an addendum dated in July 2011, the December 2010 VA examiner concluded that it is less likely than not that the Veteran has anxiety that is related to his (service-connected) minor traumatic brain injury (TBI) that occurred in the service. A VA initial PTSD disability benefits questionnaire (DBQ), dated in September 2012, shows that the examiner indicated that the Veteran's claims file had been reviewed. The Veteran's symptoms were noted to include anxiety. The Axis I diagnoses were PTSD, and past history of alcohol abuse. The Axis III diagnoses included hypertension. In a VA PTSD DBQ, dated in October 2014 the Veteran complained of symptoms that included generalized worry about "whether I am good enough for what I do," but he did not endorse symptoms of GAD (generalized anxiety disorder). The Veteran's symptoms were noted to include anxiety. The diagnosis was specified trauma and stressor-related disorder (adjustment-like disorder with prolonged duration of more than six months without prolonged duration of stressor). A VA PTSD DBQ, dated in February 2016, shows that the Veteran's VA e-folder (VBMS or Virtual VA) had been reviewed. His symptoms were noted to include anxiety. The diagnosis was depression and trauma-spectrum disorder. Overall, VA progress notes show that on several occasions, the Veteran was noted not to have hypertension. See e.g, reports, dated in November 2011, January 2012, and June 2016. A report, dated in 2013, notes complaints of psychiatric symptoms that included anxiety. Given the above, the Board finds that the claims must be denied. Under 38 U.S.C. §§ 1110, an appellant must submit proof of a presently existing disability in order to merit an award of compensation. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); see also Degmetich v. Brown, 104 F. 3d 1328 (1997). With regard to the claim for anxiety, the Board first notes that service connection is in effect for "other specified depressive disorder with other specified trauma and stressor related disorder." The Veteran's evaluation for this disability would normally include compensation for his anxiety symptoms. See 38 C.F.R. § 4.130, General Rating Formula. There is no indication that the RO has attempted to dissociate any of the Veteran's psychiatric symptoms, to include anxiety, in evaluating this disability. See generally Mittleider v. West, 11, Vet. App. 181 (1998) (holding that if it is not medically possible to distinguish the effects of service-connected and nonservice-connected conditions, the reasonable doubt doctrine mandates that all signs and symptoms be attributed to the Veteran's service-connected condition). In any event, while the Veteran clearly has symptoms of anxiety, the most probative medical evidence shows that he does not have a diagnosed anxiety disorder. Rather, he has repeatedly been found to have depressive disorders (variously characterized). This evidence includes four VA DBQs, dated in December 2010, September 2012, October 2014, and February 2016, that were based on a review of the Veteran's records. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In each case, an anxiety disorder was not diagnosed. Although the medical records contain a few scattered references to anxiety, to the extent it may be argued that these are evidence of a diagnosed anxiety disorder, these are not shown to have been based on a review of the Veteran's records, or psychological testing, and they lack indicia of reliability. They are therefore insufficient to show that the Veteran has an anxiety disorder. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997) (recognizing the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence"). Accordingly, the claim for service connection for an anxiety disorder must be denied. With regard to the claim for hypertension, there are a few scattered notations of hypertension in the medical records. However, the December 2010 VA hypertension examination report shows that the Veteran reported that he had never been diagnosed with hypertension. The examiner stated that hypertension has not been diagnosed, that there was no treatment for hypertension, and that medications were not required for control of the Veteran's blood pressure. The "diagnosis" was "normal blood pressure." There is no subsequently-dated medical evidence sufficient to show that the Veteran has been diagnosed with hypertension. Accordingly, the Board finds that the weight of the evidence is comfortably against both of the claims on a secondary basis, and that the claims must be denied. See 38 C.F.R. § 3.310. The issues on appeal are based on the Veteran's contentions that hypertension and an anxiety disorder have been caused or aggravated by a service-connected disability, specifically, the Veteran's acquired psychiatric disorder. Given the aforementioned evidence of "symptom exaggeration" and a "presentation [that] appeared consistent with compensation-seeking behaviors," during the Veteran's December 2010 VA examination, the Board finds that he is not an accurate historian. See Wilson v. Derwinski, 2 Vet. App. 16, 19-20 (1991); Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); see also March 2016 VA TBI DBQ (in which the Veteran was noted to be a poor historian). In addition, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, they fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran's post-service medical records have been discussed. He has been found not to have either of the claimed disabilities. Given the foregoing, the Board finds that the post-service medical evidence outweighs the Veteran's contentions to the effect that service connection is warranted for hypertension, or an anxiety disorder. Accordingly, the Board finds that the weight of the evidence is against the claims, and the claims are denied. The Board has considered the applicability of "benefit of the doubt" doctrine, however, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant the resolution of these matters on that basis. 38 U.S.C. § 5107 (b). Initial Compensable Evaluation In August 2011, the RO granted service connection for residuals of traumatic brain injury, evaluated as noncompensable, with an effective date for service connection of March 10, 2010. The Veteran has appealed the issue of entitlement to an initial compensable evaluation for service-connected residuals of traumatic brain injury. With regard to the history of the disability in issue, the Veteran's service and service treatment records show that he served in the Republic of Vietnam with the Marine Corps, and that his awards include the Combat Action Ribbon, and the Purple Heart. His service treatment records appear to be incomplete, but a 1969 report notes a well-healed scalp laceration, and that he had scalp sutures that were ready to be removed. The Veteran's separation examination report, dated in November 1969, does not contain any relevant complaints, findings, or diagnoses. See also reports of medical histories associated with post-active duty in the Army Reserve, dated in January 1977 and June 1981. VA reports show that a January 1990 skull X-ray was unremarkable. A private report, dated in 1993, notes complaints of syncope and migraines. On examination, cranial nerves II - XII, and a cerebellar examination, were intact. At that time, a sleep-deprived EEG (electroencephalogram) showed no epileptiform activity. A VA CT (computerized tomography) of the head, performed in August 2009, was normal. The Board notes that in July 1986, the RO granted service connection for residuals of gunshot wound to the occipital area manifested by nontender healed scar. In August 2011, the RO granted service connection for headaches, secondary to traumatic brain injury, evaluated as 10 percent disabling. Service connection is also in effect for "other specified depressive disorder with other specified trauma and stressor related disorder." The evaluations for the Veteran's scar, headaches, and his acquired psychiatric disorder are not on appeal and are not currently at issue. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection. In such a case it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Disability evaluations are determined by comparing the veteran's present symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2 (2017). The Veteran's residuals of traumatic brain injury have been evaluated as noncompensable under Diagnostic Code (DC) 8045. Under DC 8045, there are three main areas of dysfunction that may result from TBIs and have profound effects on functioning: cognitive (which is common in varying degrees after a TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, DC 8045 (2017). Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment should be evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." The rater is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The rater should consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, and labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100- percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. The table titled "Evaluation Of Cognitive Impairment And Other Residuals of TBI Not Otherwise Classified" provides the following evaluations: Impairment of memory, attention, concentration, executive functions are assigned numerical designations as follows: (0) No complaints of impairment of memory, attention, concentration, or executive functions; (1) A complaint of mild loss of memory (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; (2) Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; (3) Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; and (Total) Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Impairment of judgment is assigned numerical designations as follows: (0) Normal; (1) Mildly impaired judgment - For complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; (2) Moderately impaired judgment - For complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions; (3) Moderately severely impaired judgment - For even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; and (Total) Severely impaired judgment - For even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. For example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities. Impairment of social interaction is assigned numerical designations as follows: (0) Social interaction is routinely appropriate; (1) Social interaction is occasionally inappropriate; (2) Social interaction is frequently inappropriate; and (3) Social interaction is inappropriate most or all of the time. Impairment of orientation is assigned numerical designations as follows: (0) Always oriented to person, time, place, and situation; (1) Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation; (2) Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation; (3) Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation; and (Total) Consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Impairment of motor activity (with intact motor and sensory system) is assigned numerical designations as follows: (0) Motor activity normal; (1) Motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function); (2) Motor activity mildly decreased or with moderate slowing due to apraxia; (3) Motor activity moderately decreased due to apraxia; and (Total) Motor activity severely decreased due to apraxia. Impairment of visual spatial orientation is assigned numerical designations as follows: (0) Normal; (1) Mildly impaired - Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system); (2) Moderately impaired - Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS; (3) Moderately severely impaired - Gets lost even in familiar surroundings, unable to use assistive devices such as GPS; and (Total) Severely impaired. May be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. Subjective symptoms are assigned numerical designations as follows: (0) Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples are: mild or occasional headaches, mild anxiety; (1) Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light; and (2) Three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days. Neurobehavioral effects are assigned numerical designations as follows: (0) One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. Examples of neurobehavioral effects are: Irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects; (1) One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them; (2) One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them; and (3) One or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. Impairment of communication is assigned numerical designations as follows: (0) Able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language; (1) Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas; (2) Inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time. Can generally communicate complex ideas; (3) Inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time. May rely on gestures or other alternative modes of communication. Able to communicate basic needs; and (Total) Complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both. Unable to communicate basic needs. Impairment of consciousness is assigned numerical designations as follows: Total - Persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma. See 38 C.F.R. § 4.124a, DC 8045. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" with manifestations of a co-morbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. As an initial matter, the Board notes that separate ratings are in effect for post-concussion headaches, bilateral hearing loss, tinnitus, and "other specified depressive disorder with other specified trauma-and stressor related disorder." As such, his headache, hearing loss, tinnitus, and psychiatric symptoms have been separately evaluated under diagnostic codes other than DC 8045, and these symptoms may not be considered in the evaluation of his residuals of TBI, as this would constitute pyramiding. See 38 C.F.R. §§ 4.14, 4.124a, DC 8045 Note(1); Esteban v. Brown, 6 Vet. App. 259 (1994). The medical evidence includes a March 2011 VA neurological disorders examination report noting a history with some conflicting details, as follows: the Veteran reported a history of sustaining a grazing gunshot wound to the back of his head, in the left occipital region, due to friendly fire on April 13, 1969. He was treated and returned to duty, and requested assignment outside of Vietnam the following day. He subsequently reported treatment at a hospital in Okinawa. After being wounded, the Veteran woke up in the hospital a few days later, after being medivacked out, with headaches. He also had confusion that lasted a few weeks. Following separation from active duty, he had service in the Army Reserves, during which time he had no problems with use of his extremities, getting words out, or visual problems. In 1986, he had complaints of feeling faint, and passing out a number of times. His current symptoms primarily pertained to headaches, with some dizziness. He took Imitrex. On examination, the extraocular muscles were intact. Visual fields were full to confrontation. The face was symmetric. Facial sensation was intact to light touch, pinprick, and temperature sense. Visual acuity was 20/50 bilaterally without correction. Hearing was intact to 128 Hz and 256 Hz tuning forks, with a hearing aid in the right ear. Motor function was 5/5 throughout. He had normal muscle tone and bulk without spasticity. Reflexes are symmetric, 1/4 at the biceps and triceps, and 2/4 at the patellar and Achilles tendon. With regard to coordination, finger-nose-finger testing was intact. Sensation was intact to light touch, pinprick, temperature, and vibration sense. There was a linear scar in the occipital area, 2.5 cm. long. The diagnosis was atypical migraine headaches versus tension headaches. A July 2011 VA TBI examination report notes a history and current complaints essentially the same as those noted in the March 2011 VA examination report. In addition, the examiner stated that according to the Veteran's claims file, he had a minor injury during service, and he was able to go back into combat; he had a moderate head injury and he recovered in a few days. The Veteran stated that he had retired the year before, due to chemotherapy and right arm weakness related to surgery for right breast cancer. He had a security job one day a week, and spent the rest of his time taking care of his wife, who was ill. He reported having had a bad memory all of his life, that worsened after his chemotherapy. He has always been bad at mathematics. He frequently lost his keys and glasses. Sometimes he got lost while driving. He forgets things when he is out shopping. On examination, he did not know the presidents back to G.W. Bush. He had a good knowledge of current events. He could remember faces, but not names well. He remembered his relatives' names without difficulty. He could pay attention to something for less than half an hour, which was a lifelong trait going back to his childhood. He had difficulty memorizing the words to a song. With regard to concentration, he had difficulty completing homework. With regard to executive functioning, his wife did his finances. He did not believe that he could do so. He could not work on a car. The most difficult thing he has done in the past few years is memorizing words to karaoke songs. With regard to cranial nerve function, he had a pre-cataract in his right eye, otherwise his vision was good. He had blurred vision with headaches. He had an 80 percent hearing loss in his left ear, and left-sided tinnitus. His balance was fair, with no falls in the last six months. He had some swallowing difficulties due to ulceration of his esophagus. Food tended to get stuck. He has no speech difficulties. With regard to psychiatric symptoms, he continued to have nightmares about Vietnam, and had slept poorly at night for the last three years. He had a few good friends and mostly gets along with his wife. He had some conflicts with his stepdaughter. He disliked crowds, and when he was in a restaurant he liked to sit where he could watch everyone. He had limited right upper arm mobility secondary to breast cancer surgery. He had no seizures or blackouts. He had some left hip pain and back pain related to two dislocated discs, which resolved without physical therapy. On examination, motor strength was 5/5 throughout. There was normal muscle tone and bulk. There was increased tone of the bilateral lower extremities. Reflexes were 2/4 at the biceps, triceps, musculotaneous, patellar, and Achilles tendon. Sensation was intact to light touch, pinprick, temperature, and vibration sense in all four extremities. With regard to his gait, he took six seconds to walk 25 feet. There was no spasticity of gait, and there were normal arm swing cerebellar signs. Finger-nose-finger test was intact. There were no orthostatic symptoms on standing, and no abnormal sweating. Visual acuity was at least 20/25 on far vision. Extraocular muscles were intact. Visual fields were full to confrontation. Hearing was decreased to 128 Hz and 256 Hz on the left ear. His face was symmetric. Facial sensation was intact to light touch, pinprick, and temperature sense. With regard to cognitive impairment, he scored 24/30 on mini-mental testing. Regarding psychiatric manifestations, he was easily frustrated with cognitive testing, but no other marked anxiety was noted. There was no tangential thinking. With regard to skin breakdown and other abnormalities, he had a tattoo on his right upper forearm, and a surgical scar on his right lower quadrant. With regard to memory, attention, concentration, and executive functions, he complained of impairment in memory and executive functions. His mental status and cognitive tests were below normal. He did not relate a decline in congenitive function to his head injury. Some of his cognitive problems date at least back to his grade school years, with mathematics, and difficulty taking tests and memorization. A January 2011 neuropsychology test was noted to show cognitive difficulties that were seen to be exaggerated. That examination also documented cognitive problems that preceded his head injury. Therefore it is less likely than not that his cognitive functions are a result of his minor head injury. Judgment is normal. Social interaction is routinely appropriate. The Veteran is always oriented to person, time, place, and situation. There was normal motor activity without apraxia. There was normal visual spatial orientation. Subjectively, he had headaches with features of atypical migraines. With regard to neurobehavioral effects, the Veteran has symptoms consistent with PTSD, e.g., nightmares, poor sleep, and hypervigilance, that are less likely as not a result of his TBI. With regard to communication, he is able to communicate by spoken and written language. Consciousness is normal. The diagnosis was minor TBI with resulting migrainous headaches. A VA TBI DBQ, dated in March 2016, shows that the examination was performed on March 16, 2016. The examiner indicated that the Veteran's claims file had been reviewed. The Veteran was noted to be a poor historian, with difficulty remembering dates and the history of his medical problems. He complained of poor vision during headaches. He reported getting stressed and angry more since his service. He said that he was thinking of quitting his job of seven years as a security guard due to stress. He reported having a four to five month history of right hand tremors. In "Section II, Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI," there was a complaint of mild memory loss, i.e., losing his way when driving occasionally, but he did not use a GPS (global positioning system). He also reported problems with dates and appointments, which he writes down on a calendar. He had a good knowledge of current events. He knew the current president, but not the presidents before him. He did not remember his medications. He could paint for half an hour with sustained attention, and could start again after a break. He forgot things, such a putting his clothes in the dryer after washing them. With regard to concentration, he has poor memory of what he has read, and mostly remembers reruns on television he has seen before. With regard to executive functions, his ex-wife does his finances; he had needed help with finances for the last 15 years. He could not do online banking, and has not used a computer in years. He had some problems with planning a trip. He had been working for a security company for the last seven years. Judgment was normal. Social interaction was routinely appropriate. He was always oriented to person, time, place, and situation. Motor activity was normal. Visual spatial orientation was mildly impaired. With regard to subjective symptoms, he had subjective symptoms that do not interfere with work, instrumental activities of daily living, or work, family or other close relationships, e.g., mild or occasional headaches, and mild anxiety. There were one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction, e.g., nightmares, poor motivation, suspiciousness, and anger issues. He had good friends was able to communicate by spoken and written language, and to comprehend spoken and written language. Consciousness was normal. The report notes that muscle strength was 5/5 throughout, with normal muscle tone and bulk, without spasticity. Reflexes were 2/4 at the biceps, triceps, and musculotaneous, and 0/4 at the patellar and ankle jerk. Sensation was intact to light touch, pinprick, temperature, and vibration sense. With regard to gait, he took eight seconds to walk 25 feet, with normal arm swing and cerebellar signs, without spasticity. Finger-nose-finger testing showed mild ataxia bilaterally. Heel-to-toe was intact. The extraocular muscles were intact. Visual fields were full to confrontation. The face was symmetric. The face was symmetrical. Facial sensation was intact to light touch, pinprick, and temperature sense. Visual acuity was 20/50 bilaterally without correction. Hearing was intact to finger rustling, and 128 Hz and 256 Hz tuning forks, with bilateral hearing aids. MMSE (mini-mental state examination) testing was 26 out of 30 correct. The Veteran's ability to work was not impacted. The examiner stated that while there was some decline in cognitive functioning since 2011, this was probably due to aging and the effects of chemotherapy. For both time periods at issue, with regard to the facet "impairment of memory, attention, concentration, executive functions," the July 2011 VA examiner noted that previous cognitive testing revealed evidence of exaggeration, as well as evidence of cognitive impairment that preceded the Veteran's head injury. The examiner concluded that it is less likely than not that the Veteran's cognitive impairment was due to his head injury. This conclusion is consistent with the Veteran's self-reported history, and the March 2016 VA examiner, who attributed his cognitive impairment to conditions other than his in-service brain injury, finding that while there was some decline in cognitive functioning since 2011, this was probably due to aging and the effects of chemotherapy. Accordingly, as the only two competent opinions on this issue have ruled out the Veteran's in-service head injury as the source of his cognitive impairment, the Board finds that no more than a "0" level of impairment is warranted for this facet at any time. DC 8045. Cf. Mittleider v. West, 11, Vet. App. 181 (1998). Prior to March 16, 2016 The Board finds that an initial compensable evaluation for residuals of traumatic brain injury is not warranted prior to March 16, 2016. Upon consideration of the ten facets discussed for evaluation of cognitive impairment and other residuals of TBI not otherwise classified, none warrant assignment of more than "0" level of impairment. The evidence indicates that the Veteran has normal social interaction, orientation, motor activity (with no evidence of apraxia), visual spatial orientation, communication, and consciousness. There is no evidence of three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships. There is also no basis to find that the Veteran has physical (including neurological) dysfunction warranting a compensable evaluation. In summary, the evidence is insufficient to show that the required symptoms for an initial compensable evaluation were present in both degree and frequency. Therefore, an initial compensable evaluation under 38 C.F.R. § 4.124a, DC 8045 is not warranted prior to March 16, 2016. As of March 16, 2016 The Board finds that as of March 16, 2016, the criteria for a 10 percent evaluation have been met. The March 2016 VA examination report shows that there was mild impairment of visual spatial orientation. Thus level "1" impairment is shown for this facet, and the criteria for a 10 percent evaluation are shown to have been met as of the date of this examination, i.e., March 16, 2016. To this extent, the appeal is granted. An evaluation in excess of 10 percent is not warranted. Upon consideration of the ten facets discussed for evaluation of cognitive impairment and other residuals of TBI not otherwise classified, none warrant assignment of more than "1" level of impairment. The evidence indicates that the Veteran has normal social interaction, orientation, motor activity (with no evidence of apraxia), communication, and consciousness. There is no evidence of three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships. There is also no basis to find that the Veteran has physical (including neurological) dysfunction warranting a compensable evaluation. In summary, the evidence is insufficient to show that the required symptoms for an evaluation in excess of 10 percent were present in both degree and frequency. Therefore, an evaluation in excess of 10 percent under 38 C.F.R. § 4.124a, DC 8045 is not warranted as of March 16, 2016. The issue of whether referral for extra-schedular consideration is warranted must be argued by the claimant or reasonably raised by the record. Yancy v. McDonald, 27 Vet. App 484 (2016); see also Johnson v. McDonald, 762 F.3d 1362 (2014). In this case, neither the Veteran, nor the record, raises the issue of an extra-schedular rating for the disability in issue. Finally, although the Veteran has submitted evidence of medical disability, and is presumed to have made claims for the highest evaluations possible, in a decision dated in February 2016, the RO denied a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). Since that time, he has not submitted evidence of his unemployability, or claimed to be unemployable due to the service-connected disability in issue. He has reported that he retired due to the effects of his (nonservice-connected) chemotherapy. See July 2011 VA examination report. In March 2016, he stated that he was thinking of quitting his job of seven years as a security guard "due to stress." This was speculative in its terms, and the reference to "stress" is insufficiently specific to indicate a relationship to his residuals of a traumatic brain injury. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Board has considered the Veteran's statements that he should be entitled to an increased initial evaluation. The Board is required to assess the credibility and probative weight of all relevant evidence. In doing so, the Board may consider factors such as facial plausibility, bias, self-interest, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498, 511 (1995); Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). The Board may consider the absence of contemporaneous medical evidence when determining the credibility of lay statements, but may not determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Personal interest may affect the credibility of the evidence, but the Board may not disregard testimony simply because a claimant stands to gain monetary benefits. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Lay persons are normally competent to report neurological and physical symptoms, as these observations come to them through their senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran's belief that his symptoms are of such severity as to warrant an increased initial evaluation. However, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. The Veteran has been found not to be a credible historian. Therefore, the Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran's assessment of the severity of his disability. The VA examinations also took into account the Veteran's competent (subjective) statements with regard to the severity of his disability. In deciding the Veteran's increased evaluation claim, the Board has considered the determination in Fenderson, and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to initial increased evaluations for separate periods based on the facts found during the appeal period. As noted above, the Board does not find evidence that the Veteran's evaluation should be increased for any other separate period based on the facts found during the whole appeal period, other than as noted. The evidence of record from the day the Veteran filed the claim to the present supports the conclusion that the Veteran is not entitled to additional increased compensation during any time within the appeal period, other than as noted. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the claimed disability such that an initial increased evaluation is warranted, other than as noted. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, to the extent that the claim has been denied, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duties to Notify and Assist The Veteran has not identified any relevant records that have not been associated with the claims file, and it appears that all pertinent records have been obtained. The Veteran has been afforded examinations. There is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. Id. at 1381 (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER The claim for service connection for a depressive disorder is dismissed. Service connection for an anxiety disorder, and hypertension, is denied. Prior to March 16, 2016, an initial compensable evaluation for service-connected residuals of traumatic brain injury is denied. As of March 16, 2016, and no earlier, an evaluation of 10 percent, and no more, for service-connected residuals of traumatic brain injury is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs