Citation Nr: 1807336 Decision Date: 02/05/18 Archive Date: 02/14/18 DOCKET NO. 14-34 560A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for residuals of traumatic brain injury (TBI) with posttraumatic headaches. 2. Entitlement to an initial disability rating in excess of 50 percent for an acquired psychiatric disorder, to include depression and posttraumatic-stress disorder (PTSD). 3. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Robert Chisholm, Attorney ATTORNEY FOR THE BOARD J. Meyer, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1988 to July 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal of an October 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In November 2015, the Board denied entitlement to a rating in excess of 10 percent for residuals of a TBI with posttraumatic headaches and remanded the other issues on appeal. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2016 Order, the Court vacated and remanded the November 2015 decision, pursuant to an April 2016 Joint Motion for Partial Remand (JMR). The Board subsequently remanded the claims on appeal in November 2016 and August 2017 for more development. After further development, these matters are ready for adjudication. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's service-connected residuals of TBI have been manifested by subjective complaints of memory loss, attention, concentration, and/or executive functions, as well as daily headaches, hypersensitivity to light, hypersensitivity to sound, and nausea that mildly interfere with work, instrumental activities of daily living, or work, family, or other close relationships. 2. Throughout the period on appeal, the Veteran's psychiatric disorder has been characterized by panic attacks, sleep disturbances, depression, anxiety, and difficultly in establishing and maintaining effective social relationships. Moreover, occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as active suicidal ideation, obsessional rituals which interfere with routine activities, near-continuous panic or depression affecting ability to function independently, appropriately and effectively, spatial disorientation, speech that is intermittently illogical, obscure, or irrelevant, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships, have not been shown. 3. The evidence does not indicate that the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent rating for residuals of TBI with posttraumatic headaches have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8045 (2017). 2. The criteria for an initial disability rating in excess of 50 percent for an acquired psychiatric disorder, to include depression and PTSD, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9434 (2017). 3. The criteria for entitlement to TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings The Veteran is seeking increased ratings for his service-connected residuals of TBI and psychiatric disorder. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7 (2017). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). In the case of an initial rating, the entire evidentiary record from the time of a veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability. Fenderson v. West, 12 Vet. App. 119 (1999). Further, the Board must consider whether the disability has undergone varying and distinct levels of severity while the claim has been pending and provide staged ratings during those periods. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Traumatic Brain Injury The Veteran was originally assigned a 10 percent rating for residuals of his service-connected traumatic brain injury (TBI) due to posttraumatic headaches under 38 C.F.R. § 4.124a, DC 8045. The Board notes that VA amended the Schedule for Rating Disabilities by revising the portion of the Schedule that addresses neurological conditions and convulsive disorders to provide updated criteria for evaluating residuals of TBI. The amendment applies to all applications for benefits received by VA on or after October 23, 2008. 73 Fed. Reg. 54,693 (Sept. 23, 2008). However, as in this case, a veteran whose residuals of TBI were rated under a prior version of 38 C.F.R. § 4.124a, DC 8045, is permitted to request review under the new criteria. Id. Therefore, under the current DC 8045, there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: emotional/behavioral, cognitive (which is common in varying degrees after a traumatic brain injury), and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a. Cognitive impairment is defined as "decreased memory, concentration, attention, and executive functions of the brain." The term "executive functions" includes factors such as 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. The extent of cognitive impairment is evaluated under the table contained in 38 C.F.R. § 4.124a, which addresses "Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." The table for evaluating cognitive impairment addresses 10 facets of a traumatic brain injury related to cognitive impairment and subjective symptoms, and provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, as well as a 5th level, the highest level of impairment, labeled "total." These facets include memory, attention, concentration and executive function, judgment social interaction, orientation, motor activity, visual and spatial orientation, neurobehavioral effects, communication, consciousness, and other "subjective symptoms." If no facet is evaluated as "total," the overall percentage evaluation is assigned 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, if one facet is classified as a 3, then a 70 percent evaluation is assigned. When a veteran displays subjective symptoms, such symptoms should be applied to this table, unless the symptoms may be evaluated under another diagnostic code. For example, if there are any emotional or behavioral symptoms that have been clinically diagnosed, such symptoms should be evaluated under the schedule of ratings for mental disorders listed in 38 C.F.R. § 4.130. Similarly, if the residuals of the TBI include other diagnosable symptoms such as (but not limited to) motor and sensory dysfunction, visual impairment, hearing loss and tinnitus, loss of sense of smell and taste, or any other disorders, they should be evaluated under the appropriate diagnostic code, and then combined under 38 C.F.R. § 4.25. A. Cognitive Impairment Based on the history of this appeal, the Veteran's current 10 percent rating has been based on a finding of cognitive impairment. As such, in order to warrant a rating in excess of 10 percent, the evidence must show a symptoms equivalent to a "2" or "3" as the highest level of any one cognitive facet, or a "total" evaluation to be assigned for one or more facets relating to cognitive impairment. 38 C.F.R. § 4.124a. Based upon the evidence of record, a rating in excess of 10 percent is not warranted as the highest level of severity for any cognitive facet during the period on appeal is "1" under the criteria set forth in 38 C.F.R. § 4.124a. Specifically, in a September 2014 examination, the Veteran had complaints of mild memory loss, attention, concentration, and/or executive functions. On examination, the examiner determined that the Veteran did not have any objective evidence of impairment related to his memory, attention, concentration, and/or executive functioning. Moreover, his judgment, orientation, consciousness, motor activity, visual spatial orientation, and communication were all essentially normal or within normal limits. In a December 2016 VA examination, the Veteran had complaints of mild memory loss, attention, and concentration, but there was no objective evidence of a deficiency in these areas impairment on testing. There was no evidence of impairment with the Veteran's judgment, orientation, motor activity, communication, and consciousness to warrant a higher rating. Additionally, while the Veteran had mildly impaired visual spatial orientation due to the fact that he "occasionally gets lost," he did not display impairment to a moderate degree that would warrant a higher rating. In considering whether or not the Veteran is entitled to a higher rating for cognitive impairment as a result of his TBI, the Board acknowledges the Veteran's October 2012 private opinion which discusses various moderate cognitive impairments that were present prior to the period on appeal and unrelated to the current period on appeal. Moreover, to the extent the Veteran's private physician indicates that the Veteran has current cognitive impairments, her opinions are not sufficiently supported by the medical evidence, and her opinions are conclusory and/or based upon the Veteran's reported symptomatology. As a result, the Board finds these opinions to be less probative. B. Emotional and Behavioral Impairments Next, the Board determines that the Veteran does not have any emotional or behavioral impairment that is related to his TBI. In any event, to the extent that he has asserted that he does experience such residuals, these symptoms are already addressed in the rating for his service-connected acquired psychiatric disorder. Compare Clemons v. Shinseki, 23 Vet. App. 1 (2009) with Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). Therefore, the symptoms that are also associated with the Veteran's acquired psychiatric disorder will be discussed below, and are not to be considered in the Veteran's rating for residuals for a TBI. C. Physical Impairments The Board has considered whether the Veteran's subjective physical complaints qualify for a separate disability rating under 38 C.F.R. § 4.124a. Specifically, a higher 40 percent rating is warranted when the evidence demonstrates 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. 38 C.F.R. § 4.124a. In a September 2014 VA examination, the examiner noted three or more subjective symptoms that mildly interfered with work, instrumental activities or daily living; or work, family or other close relationships. In particular, he identified headaches, light sensitivity, sound sensitivity, nausea and frequent insomnia. However, he indicated that these symptoms only caused "mild" impairment with work, instrumental activities or daily living; or work, family or other close relationships. In a December 2016 VA examination, the Veteran only reported physical symptoms related to headaches, and the examiner determined that they do not interfere with work-place or social interactions. Therefore, a rating in excess of 10 percent is not warranted. Next, the Board has considered whether or not the Veteran's TBI residuals can be assigned a separate compensable rating under the appropriate diagnostic code. See 38 C.F.R. § 4.124a, DC 8045. With respect to headaches, under DC 8100, a compensable rating is for application when the Veteran's headaches are accompanied by prostrating attacks occurring twice a month, on average, over the past several months. Nevertheless, in this case, a separate compensable rating is not warranted for the period on appeal as the evidence does not demonstrate that the Veteran's headaches manifested by characteristic prostrating attacks. Specifically, in a September 2014 VA examination, the examiner noted that the Veteran had headache pain that typically lasted less than one day, and was associated by symptoms that include nausea, vomiting, sensitivity to light and sound. However, the examiner determined that he did not have characteristic prostrating attacks of pain. In his most recent December 2016 VA examination, the examiner opined that the Veteran's current headaches are not related to his TBI. Nevertheless, the examiner indicated that the Veteran's current headache condition is "mild" and does not cause characteristic prostrating pain with or without the ameliorative effects of his headache treatments, including mediation regimen. Moreover, while the Veteran indicated in a November 2017 correspondence that his headaches are painful and cause memory loss, communication difficulties, and dizziness, the Board does not consider the Veteran's symptoms to reach the level of "prostrating," as contemplated by the diagnostic code as the evidence does not indicate that he is physically helpless due to his headaches. The Board notes that the Veteran's treatment records do not indicate that the Veteran suffered from headaches with characteristic prostrating pain during the period on appeal. Specifically, although the Veteran reported daily headache episodes, it is not sufficient to demonstrate a particular frequency of headaches. Rather, the headaches must be also of a specific prostrating character. Accordingly, the Board finds that the intensity of the Veteran's TBI headache residuals do not warrant a separate compensable rating under DC 8100. In arriving at this conclusion, the Board acknowledges the Veteran's October 2016 opinion from his private medical provider which indicates that his headaches cause debilitating episodes several times a week and significantly interferes with his work and activities of daily living. Nevertheless, the Board finds these opinions to be less probative as they appear to be based primarily on the Veteran's statements and not sufficiently supported by the medical evidence. Moreover, it is unclear which medical records the October 2016 medical provider reviewed, and it is noted that the consultation/examination with the Veteran was performed via phone. As such, the Board finds the opinions from the VA examiners to be more probative as they performed a comprehensive physical examination and detailed review of the medical records. Further, the conclusions of the VA examiners, including the December 2016 examiner, were adequately supported by the medical evidence and contained a thorough rationale regarding the etiology and nature of the Veteran's headache disorder during the period on appeal. Additionally, the Board notes that to the extent that the Veteran has nausea, vomiting, insomnia, sensitivity to light and sound due to his headaches, those are not distinct diagnosed disorders and do not qualify for a separate rating and, in any event, the Board concludes that these symptoms are already addressed in his currently-assigned disability ratings. As such, there are no other disorders for which a separate compensable rating is warranted. In sum, a rating in excess of 10 percent for residuals of a TBI is not warranted for the period on appeal. Psychiatric Disorder The Veteran's psychiatric disorder, diagnosed as depression and PTSD, was assigned an initial disability rating of 50 percent under 38 C.F.R. § 4.130, Diagnostic Code 9434. In order to warrant a 70 percent rating, the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control (such as unprovoked irritability with periods of violence); near-continuous panic or depression affecting ability to function independently, appropriately and effectively; spatial disorientation; speech intermittently illogical, obscure, or irrelevant; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. After a review of the evidence of record, the Board determines that a rating in excess of 50 percent is not warranted. Indeed, while the Veteran has occasional symptoms that could support a higher rating, the Veteran's symptoms do not otherwise cause social and occupational impairment with deficiencies in most areas of his daily living. Specifically, as noted in the December 2012 VA treatment records, the Veteran presented for his appointment casually dressed and well groomed. He displayed symptoms that included depression, anxiety, obsessive compulsive behaviors, and panic attacks. The medical provider noted that he maintained good eye contact, normal speech, coherent and goal directed thoughts with fair insight and judgement. There was no evidence of a psychosis or thought disorder, and the Veteran denied any suicidal ideations. In a July 2013 VA examination, the Veteran appeared appropriately dressed and groomed. The Veteran exhibited symptoms of anxiety, depression, panic attacks, memory impairment, nausea, dizziness, sleep impairment, shortness of breath and heart palpitations. On examination, the Veteran was clam, cooperative, coherent, oriented in all spheres, displayed fair insight/judgment, and his speech and thought process were average. There was no evidence of a psychosis, delusions, hallucinations, suicidal/homicidal ideations, near continuous panic attacks, or grossly inappropriate behavior. In October 2013, the Veteran presented to his VA treatment evaluation oriented across all spheres, casually dressed, well groomed, and his speech was normal in rate and tone. His thought process was linear, goal directed, and without hallucinatory, homicidal or suicidal content. In a September 2014 VA examination, the examiner opined that the Veteran's psychiatric symptoms caused occupational and social impairment with reduced reliability and productivity. The examiner indicated that the Veteran exhibited depressed mood, anxiety, suspiciousness, near continuous panic attacks, chronic sleep impairment, mild memory loss, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to a work-like setting. In a June 2015 VA treatment evaluation, the Veteran was well-groomed with normal speech and thought process without any evidence of suicidal ideations, psychosis, or thought disorder. In a December 2016 VA examination, the Veteran presented as casually dressed with "good" hygiene. He had symptoms of depressed mood, anxiety, panic attacks weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work and work-like environment. On examination, he was friendly, cooperative, and displayed logical and goal directed thoughts with "good" insight and judgement. There was no evidence of a thought disorder, psychosis, hallucinations, or suicidal/homicidal ideations. As a result, the examiner stated that the Veteran's psychiatric symptoms caused 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. Therefore, the Board finds that the Veteran does not exhibit objective symptoms that would be sufficient to warrant a rating in excess of 50 percent for the period on appeal. Indeed, while it is true that the Veteran had depression, anxiety, mood disturbances, sleep impairments, and panic attacks, these symptoms alone are insufficient to warrant an increased rating given the otherwise relatively mild array of symptoms and impact on the Veteran - especially given the fact that the Veteran displayed clear, logical, goal oriented speech and thought processes without suicidal ideation throughout this period on appeal. Indeed, many of the examples listed in the diagnostic code for a higher rating have not been shown at all. In arriving at this conclusion, the Board acknowledges the October 2016 opinion from the Veteran's private medical provider which reflects that the Veteran's psychiatric disorder causes deficiencies in most areas due to symptoms such as suicidal ideation, near-continuous depression affecting the ability to function independently, impaired impulse control with periods of violence, difficulty adapting to stressful circumstances, and an inability to establish and maintain effective relationships. Nevertheless, the Board finds these opinions to be less probative as these conclusions are not sufficiently supported by the objective medical evidence. In fact, the Board notes that many of the symptoms reported by the private medical provider, including suicidal ideation and impaired impulse control with periods of violence, are contradicted by the previously discussed medical evidence. As such, the opinions from the VA examiners - which were based upon a comprehensive physical examination, detailed review of the medical records, and supported by a thorough rationale - are more probative, especially in light of the fact that the opinions and findings are consistent with the objective medical evidence. Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). As such, the Board has also considered the extent to which there are other indications of occupational and social impairment, such as difficulty in adapting to stressful circumstances or the inability to establish and maintain effective relationships that may cause deficiencies in most areas, to include social and occupational inadaptability. In this regard, it is clear that the Veteran's disorder reflects some impact on his social and occupational functioning. Nevertheless, the evidence does not indicate that a rating in excess of 50 percent is warranted. Specifically, while the Veteran and his wife are separated and he reports that he isolates himself socially, he nevertheless maintains a stable relationship with his children and brother, and he is able to leave the house as needed. Further, while the Veteran was not employed, he indicated that his lack of employment was due primarily to his headaches and the fact that he has a prior DUI conviction. Therefore, his level of social occupational impairment was not deficient in most areas even when factoring in other relevant criteria outside of the rating code. See Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). The Board has also considered the Veteran's Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran's GAF scores reported by his private mental health providers and VA examiners were between 55 and 65. A GAF of 51-60 reflects "moderate" symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or "moderate" difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). On the other hand, a GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. In this case, the Veteran's GAF score has ranged from 55 to 65. In the Board's view, the Veteran's symptoms are most consistent with the more "moderate" symptoms reflected in a GAF score of 51 to 60, considering that there was no suicidal ideation, severe obsessional rituals, or evidence of any psychosis or thought disorder. However, such symptoms are not so severe as to warrant a rating in excess of 50 percent. In considering the appropriate disability rating, the Board has also considered the statements from the Veteran that his residuals of a TBI and acquired psychiatric disorder are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his TBI and acquired psychiatric disability according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). On the other hand, such competent evidence concerning the nature and extent of the Veteran's service-connected disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Specifically, with respect to his psychiatric disorder, while the Veteran reported that he had depression, anxiety, and panic attacks, these symptoms were discussed and addressed by the VA examiners and treating medical providers. Further, other symptoms such as suicidal ideations occurred outside the appeal period. Additionally, with respect to the Veteran's headache disorder, the medical examiners and treating medical providers addressed and discussed the nature and severity of his headaches and related pain. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all of his relevant symptoms related to the issues on appeal, including limitations with activities of daily living, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes. See Mittleider v. West, 11 Vet. App. 181 (1998). Moreover, as was established in Mauerhan, 16 Vet. App. at 444, a schedular rating for psychiatric disorders is not necessarily limited to the enumerated symptoms in the general rating formula, and no relevant symptoms have been excluded in the Board's analysis. As such, the Veteran's symptoms are not which are so unusual that they are outside the schedular criteria. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU The Veteran has asserted that he is unable to work because of his service-connected disabilities. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1) (2017). A total disability rating for compensation purposes may be assigned on the basis of "individual unemployability," or when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a) (2017). In such an instance, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. If a Veteran fails to meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extra-schedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b). See also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age, which would justify a TDIU. 38 C.F.R. §§ 3.341(a), 4.19; See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). After a review of the evidence of record, the Board determines that TDIU is not warranted for the period on appeal. As an initial matter, the Veteran has met the schedular rating for the entire period on appeal. Specifically, his service-connected psychiatric disorder is rated at 50 percent, and TBI residuals rated at 10 percent. Thus, the Veteran's overall combined rating is 60 percent (with one disability rated higher than 40 percent). Even so, TDIU is not warranted on a factual basis. Specifically, prior to June 2014, the Veteran was able to work "50+" hours as a manager of a trucking business. Therefore, the Veteran was clearly substantially gainfully employed - and the Veteran does not allege otherwise. Further, as of June 2014, the Board determines that the Veteran's service-connected disabilities did not prevent him from securing or following a substantially gainful occupation. See 38 C.F.R. § 4.16(b). Specifically, in September 2014, after a thorough examination and detailed review of the Veteran's records, the VA examiner reported that the Veteran's mental symptoms were not severe enough to prevent him from obtaining and retaining gainful employment. Specifically, the examiner noted that the Veteran's depression, anxiety, sleep impairment, social impairment, etc., did not prevent him from working. Additionally, the Veteran stated that he lost his job because his employer was "cutting expenses," rather than from his service-connected disorders. Similarly, the Veteran's November 2015 VA treatment records report that the Veteran applied for a job with a local school. However, he stated that he did not get the job "because of a DUI charge more than 10 years in the past." At a VA examination in December 2016, while the examiner indicated that the Veteran's service-connected disabilities impacts his ability to work - specifically, due to his "irritability, anger, and difficulty with dealing with people" - there was no indication that the Veteran was unable to work or maintain gainful employment. In fact, the examiner determined that the Veteran's memory was only mildly impaired and that his judgment, communication, social interactions, and behavior were all essentially normal. Additionally, the Board notes that to the extent the Veteran claims his headaches prevent him from working, an August 2017 VA addendum opinion from a Board Certified neurologist concluded that after a thorough review of the Veteran's medical record and previous examination reports, his current headache disorder is not related to his TBI. Additionally, the Board acknowledges the October 2016 opinion from the Veteran's private medical provider which indicates that he is unable to maintain gainful employment "in any capacity." The Board notes that the rationale focused almost exclusively on the Veteran's headaches and memory impairment. However, these findings were not supported by the objective medical evidence. With respect to the Veteran's psychiatric disorder, the Veteran's physician merely stated without sufficient supporting rationale that his current level of symptoms has resulted in "occupational and social impairment with deficiencies in most areas." As a result, the Board determines that the opinions from the VA examiners to be more probative as they are supported by the objective medical evidence and the rationales are sufficiently detailed. The Board has also considered the statements from the Veteran which indicate that he has substantial employment limitations and frequently needs to take significant amounts of time off of work due to his service-connected disabilities. Nevertheless, the Board assigns more probative weight to the well-reasoned medical opinions from the VA examiners, as well as the medical evidence which indicates that the Veteran's service-connected disabilities did not prevent him from obtaining and retaining substantial gainful employment. Therefore, the weight of the evidence is against the Veteran's TDIU claim. In sum, the Board determines that the Veteran was able to engage and maintain substantially gainful employment during the period on appeal. As such, the Veteran's TDIU claim is denied. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). VA Duty to Notify and Assist The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA), which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). The VCAA also redefines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. 38 U.S.C.A. §§ 5103, 5103A. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2016); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was provided notice letters informing him of both his and VA's obligations. Moreover, there is no indication of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Therefore, additional notice is not required and any defect in notice is not prejudicial. With respect to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C.A. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). The Board finds that all necessary assistance has been provided to the Veteran. Indeed, all VA treatment records and relevant private treatment records have been obtained. As per the Board's November 2016 and August 2017 remand instructions, the Veteran has been provided with a VA examination as discussed below. Finally, it is noted that this appeal was remanded by the Board in November 2016 and August 2017 in order to obtain outstanding medical treatment records and a new VA examination and addendum opinion. To the extent that the appeal is being adjudicated, the Board is now satisfied there was substantial compliance with this Remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Specifically, all outstanding medical records were obtained. Further, the Veteran was provided with a VA examination in December 2016 to specifically address whether or not he had characteristic prostrating headache attacks, without consideration of the ameliorative effects of his medications. Upon review of the examination report, the Board observes that the examiners reviewed the Veteran's past medical history, recorded his current complaints and history, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Further, the examiner specifically opined that the Veteran did not have prostrating headaches with or without the use of medication. Therefore, the VA examination report is adequate for the purpose of rendering a decision on appeal. 38 C.F.R. § 4.2 (2016); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, the Board notes that the issue was again remanded in August 2017 for an addendum opinion to address the reasons and basis for the December 2016 VA examiner's finding that the October 2016 private opinion was inadequate due to certain "inconsistencies." Nevertheless, the Board finds that while the August 2017 VA addendum opinion did not specifically address each "inconsistency," there was still substantial compliance with the remand as the VA examiner specifically determined that the Veteran's current headache disorder is not related to his TBI. Thus, the examiner's opinion addressing the private physician's inconsistencies on the issue of prostrating attacks would be of little value to the adjudication of the claim given that the severity of the Veteran's current headache disorder is not relevant for rating purposes. As such, the Board finds that the VA examination is sufficient and any deficiency is not prejudicial to the Veteran. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015), cert. denied, 137 S. Ct. 33, 196 L. Ed. 2d 25 (2016); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying the exhaustion doctrine to uphold the Court's determination not to consider a duty to assist argument that the veteran had not raised before the Board). Overall, no further notice or assistance is required to fulfill VA's duty to assist in the development of the above-cited claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A disability rating in excess of 10 percent for residuals of TBI with posttraumatic headaches is denied. An initial disability rating in excess of 50 percent for an acquired psychiatric disorder, including depression and PTSD, is denied. TDIU is denied. ____________________________________________ B.T. KNOPE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs