Citation Nr: 21001041 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 10-47 930 DATE: January 6, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is granted. Entitlement to service connection for an overreactive bladder is granted. Entitlement to an increased rating of 30 percent, but no higher, for tinea versicolor, prior to July 11, 2019, is granted. Entitlement to an increased rating in excess of 30 percent for tinea versicolor, from July 11, 2019, is denied. Entitlement to an increased rating of 50 percent, but no higher, for headaches is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s PTSD and MDD are related to in-service stressors. 2. The Veteran’s overreactive bladder is a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology which manifested to a compensable degree after service separation. 3. Prior to July 11, 2019, the evidence is at least in relative equipoise as to whether the Veteran’s service-connected tinea versicolor affected at least 20 percent, but less than 40 percent, of the entire body; systemic therapy has not been required. 4. From July 11, 2019, the Veteran’s service-connected tinea versicolor does not affect more than 40 percent of the entire body; systemic therapy has not been required. 5. The Veteran’s headaches have been manifested by very frequent headaches that are completely prostrating, prolonged, and productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria to establish service connection for an acquired psychiatric disorder, diagnosed as PTSD and MDD, have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria to establish service connection for an overreactive bladder have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for an increased rating of 30 percent, but no higher, for tinea versicolor, prior to July 11, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7806. 4. The criteria for an increased rating in excess of 30 percent for tinea versicolor, from July 11, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7806. 5. The criteria for an increased rating of 50 percent, but no higher, for headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training (ACDUTRA) from May 1980 to July 1980 and on active duty from December 1990 to September 1991, to include overseas service in Southwest Asia. The Veteran had several years of service in the Army National Guard. See service personnel records (SPRs). The Veteran filed his claims in a July 2007 VA Form 21-526 and June 2009 correspondence. The Veteran appealed July 2008 and December 2009 rating decisions by the Agency of Original Jurisdiction (AOJ). In November 2017 and February 2019, the Board of Veterans’ Appeals (Board) remanded the Veteran’s claims to the AOJ for further action consistent with the Board’s remand directives. The claims are back before the Board for further appellate proceedings. The Board finds there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection A veteran is entitled to the Department of Veteran Affairs (VA) disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). 1. Acquired Psychiatric Disorder The evidentiary record shows diagnoses and claims for PTSD, depression, dysthymia, and anxiety. The Board will expand the scope of the Veteran’s claim to encompass an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009); Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptoms and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Within the legal framework for evaluating claims of service connection for PTSD, the sufficiency of a stressor is a medical determination, while the occurrence of the stressor is a legal determination. Sizemore v. Principi, 18 Vet. App. 264 (2004). Psychiatrist M.R., a VA psychiatrist, diagnosed the Veteran with PTSD and MDD and noted the stressors of traumatic war experience in 1991. See October 2013 Psychiatrist M.R. DBQ. The Veteran relates his psychiatric disorder to various stressors while serving in Southwest Asia. This includes witnessing burning bodies, hearing explosions, and the fear of chemical attacks and contamination. See July 2000, February 2010, and August 2012 Veteran statements. The Veteran served in Southwest Asia and was a driver and worked with ammunition. See September 1991 DD Form 214 and SPRs. The Veteran’s September 1991 service treatment records (STRs) noted nervous trouble and frequent trouble sleeping. Given the Veteran’s duties with transportation and working with ammunition, and the environment of the Persian Gulf War posing a possibility of chemical attacks, for purposes of this opinion only, the Board finds the Veteran’s alleged stressors outlined above actually occurred. As to nexus, the October 2010 VA examiner noted the Veteran met the PTSD stressor criteria for his exposure to chemical warfare, antidotes, and the burning of oil wells and trash pits while in Kuwait. Social worker R.O., a counselor for VA, stated in an August 2012 letter that the Veteran was being treating for PTSD and noted the Veteran’s exposure to rocket attacks and fear of dying at war. The August 2016 VA examiner noted the Veteran’s stressors, of being confused with an alarm and not wearing his mask and seeing dead soldiers and burned people, were adequate to support a diagnosis of PTSD as being related to his fear of hostile military or terrorist activity. Psychologist C.R.’s September 2017 letter found the Veteran’s PTSD is related to service and his trauma precipitated his MDD. Psychologist C.R. provided a detailed history and adequate rationale. The Board find’s Psychologist C.R.’s opinion probative. November 2008 treatment records noted the Veteran’s statements that he has had the feelings of sadness, anxiousness, and irritability since serving in the military in 1991. The Veteran stated in September 2003 that his psychological health has been worsening since serving in the Gulf War. In October 2006 the Veteran stated he has had anxiety since active duty. The Veteran’s spouse stated that the Veteran’s personality has not been the same since returning from the Gulf War, that he spends his time sitting in a nervous state, and that he forgets things quickly. See May 2000 and November 2016 Spousal statements. Because the Veteran has PTSD and MDD which have been medically related to an in-service stressors, service connection for an acquired psychiatric disability, diagnosed as PTSD and MDD, is granted. 2. Bladder Condition Service connection also may be warranted for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). A MUCMI is defined by a cluster of signs or symptoms, and specifically. 38 C.F.R. § 3.317(a)(2)(ii). It means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. MUCMIs of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Signs or symptoms that may be a manifestation of an undiagnosed illness or a MUCMI include neurological signs or symptoms. 38 C.F.R. § 3.317(b). As noted above, the Veteran is a Persian Gulf veteran who served in the Southwest Asia theater. Medical evidence throughout the appellate period notes the Veteran to have hypertonicity of the bladder, being an overactive bladder. See July 2013 Treatment record; December 2017 VA examination report. The Veteran stated he had urinary issues during his deployment to Southwest Asia. See October 2017 Veteran statement. The Veteran is competent to testify to the existence of urinary issues during service. Dr. A.A.’s September 2017 letter found the Veteran’s neurogenic bladder condition, to include overactive bladder, is part of a constellation of symptoms that are more likely than not consistent with a diagnosis of Gulf War veterans’ medically unexplained illness. Dr. A.A. stated the Veteran had no medical issues prior to service and then after service he developed symptoms that impacted almost every system within his body, leading to the logical conclusion that there is a systemic etiology causing a multi-symptom illness. Dr. A.A. provided a detailed history and thorough rationale. The Board find’s Dr. A.A.’s opinion probative. No other medical opinion has been rendered that considers the presumptions and criteria for Gulf War veterans. The December 2017 VA examiner provided a negative direct nexus opinion with limited details and without adequate rationale. Based on Dr. A.A.’s opinion, the Board finds the greater weight of the evidence of record shows that the Veteran’s bladder condition is a MUCMI. Although the Veteran contends that his bladder symptoms started in service, the evidence also shows that his bladder condition has manifested to a degree of 10 percent or more. The Veteran’s overreactive bladder is rated pursuant to Diagnostic Code 7542 for neurogenic bladder, which is rated as a voiding dysfunction, effective August 29, 2011. Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. 38 C.F.R. § 4.115a. Only the predominant area of dysfunction shall be considered for rating purposes. Id. The Veteran’s predominant area of dysfunction is urinary frequency. A 10 percent rating contemplates a daytime voiding interval between two and three hours, or awakening to void two times per night. A 20 percent rating contemplates a daytime voiding interval between one and two hours, or awakening to void three to four times per night. The maximum 40 percent rating contemplates a daytime voiding interval less than one hour, or awakening to void five or more times per night. The December 2017 VA examiner noted the Veteran to have a daytime voiding interval less than 1 hour and nighttime awakening to void 5 or more times. As such, the Veteran’s bladder disability is consistent with a 40 percent evaluation. In light of the foregoing, the Board finds that the evidence is at least in a state of relative equipoise on all material elements of the claim under 38 C.F.R. § 3.317. Accordingly, service connection for an overreactive bladder is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating When a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where the question to consider is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a “staged” rating are required. See Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Importantly, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998); 38 C.F.R. § 3.102. 1. Tinea Versicolor The Board notes the Veteran’s rating for his service-connected tinea versicolor was increased to 30 percent in an April 2020 rating decision effective July 11, 2019. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (as effective from October 23, 2008 to August 13, 2018). For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a Veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug. Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations clarify that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies. See 38 C.F.R. § 4.118. Under this new formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned for at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (as effective from August 13, 2018). The Federal Circuit found it was error to read the diagnostic code “as unambiguously elevating any form of corticosteroid treatment, including any degree of topical corticosteroid treatment, to the level of ‘systemic therapy.” Johnson v. Shulkin, 2016-2144, 2017 U.S. App. LEXIS 12601 (Fed. Cir. 2017). The Federal Circuit went on to explain that “systemic therapy means ‘treatment pertaining to or affecting the body as a whole,’ whereas topical therapy means ‘treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.’” Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. A. Prior to July 11, 2019 The August 2007 VA examination report noted a cream was used and applied daily and that the condition was located on the feet. The February 2016 VA examination report noted skin spots on the Veteran’s anterior trunk, the use of topical corticosteroid for 6 weeks or more, but not constantly, and that less than 5 percent of the total body area is impacted. In response to the February 2016 VA examination report, the Veteran stated he has a rash all over his arm, back, chest, and legs. See January 2019 Correspondence. In August 2020 correspondence, it was indicated that the Veteran suffered from wide-spread rashes covering large portions of his body since at least December 2008. Overall, the AOJ increased the Veteran’s rating to 30 percent for tinea versicolor based on his July 2019 VA examination report. The July 2019 VA examination report was prompted by the Veteran’s January 2019 statement. As such, the Veteran’s skin condition must have been at 30 percent disabling levels prior to July 2019. Additionally, the Veteran’s January 2019 statement was in response to the February 2016 VA examination. The Veteran is competent to attest to the existence and location of his rashes on his body. As such, given the Veteran’s statements and for the entire appellate period, a 30 percent rating is warranted for rashes affecting 20 to 40 percent of the Veteran’s total body surface area under Diagnostic Code 7806, both former and current. The Board has considered whether a rating higher than 30 percent is warranted under the former criteria prior to August 13, 2018, and under the former or current criteria from August 13, 2018. A higher rating however, is not available under either iteration of the diagnostic criteria. The evidence has not shown that the Veteran’s rash has ever manifested in more than 40 percent of his total body or exposed body. The Veteran has given locations on his body the rash is present, but does not provide specific details as to its coverage. The Veteran and his representative have not alleged or submitted argument contenting the Veteran should be granted a rating higher than 30 percent for the skin condition. See August 2020 Correspondence. Accordingly, a higher rating is not available under either version of the criteria based on size. Turning to medication, the evidence of record demonstrates that the Veteran has only treated his rash with topical medications. This mainly includes various skin ointments and creams. As noted above, in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit held that a topical corticosteroid treatment could meet the definition of systemic therapy [under the former rating criteria] if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In this case, the Board does not find the Veteran’s use of topical cream used during the period under review, to be “systemic” treatment as application was limited to the affected areas, and there is no evidence of record demonstrating that such topical treatment pertains to or affects the body as a whole. Accordingly, although the Veteran’s applies topical treatment, such treatment was not systemic or constant/near-constant, as required by the former rating criteria to warrant the higher 60 percent rating. Under the current rating criteria, by definition, topical treatment through the skin cannot be systemic, so a higher rating is also unavailable. The Board has considered whether a rating for disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805) is warranted, but finds that ratings under these Diagnostic Codes are not appropriate in this case. At no time during the period under review has the Veteran alleged, or have physicians identified the presence of disfiguring scars of the head, face or neck, or scarring other than on the head, face or neck that is deep or cause limited motion related to his tinea disabilities. As such, the criteria outlined in former Diagnostic Codes 7800 and 7801 are not applicable. Similarly, the evidence does not demonstrate superficial scarring due to tinea disability, or that the Veteran’s skin disability limits the functioning of any affected part of his body. Therefore, ratings under former Diagnostic Codes 7802-7805 are also not applicable. In conclusion, the Board finds that the Veteran is entitled to a 30 percent increased rating, but no higher, for service-connected tinea versicolor, prior to July 11, 2019. B. From July 11, 2019 The July 2019 VA examination report noted the Veteran’s condition was treated with hydrocortisone creams and that the condition impacted 20 to 40 percent of his total body area. Given the above evidence, the Board finds a 30 percent rating is proper from July 11, 2019. A higher rating however, is not available under either iteration of the diagnostic criteria. The evidence has not shown that the Veteran’s rash has ever manifested in more than 40 percent of his total body or exposed body. The Veteran has given locations on his body the rash is present, but does not provide specific details as to its coverage. The Veteran and his representative have not alleged or submitted argument contenting the Veteran should be granted a rating higher than 30 percent for his skin condition. See August 2020 Correspondence. Accordingly, a higher rating is not available under either version of the criteria based on size. Turning to medication, the evidence of record demonstrates that the Veteran has only treated his rash with topical medications. This mainly includes various skin ointments and creams. As noted above, in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit held that a topical corticosteroid treatment could meet the definition of systemic therapy [under the former rating criteria] if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In this case, the Board does not find the Veteran’s use of topical cream used during the period under review, to be “systemic” treatment as application was limited to the affected areas, and there is no evidence of record demonstrating that such topical treatment pertains to or affects the body as a whole. Accordingly, although the Veteran’s applies topical treatment, such treatment was not systemic or constant/near-constant, as required by the former rating criteria to warrant the higher 60 percent rating. Under the current rating criteria, by definition, topical treatment through the skin cannot be systemic, so a higher rating is also unavailable. The Board has considered whether a rating for disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805) is warranted, but finds that ratings under these Diagnostic Codes are not appropriate in this case. At no time during the period under review has the Veteran alleged, or have physicians identified the presence of disfiguring scars of the head, face or neck, or scarring other than on the head, face or neck that is deep or cause limited motion related to his tinea disabilities. As such, the criteria outlined in former Diagnostic Codes 7800 and 7801 are not applicable. Similarly, the evidence does not demonstrate superficial scarring due to tinea disability, or that the Veteran’s skin disability limits the functioning of any affected part of his body. Therefore, ratings under former Diagnostic Codes 7802-7805 are also not applicable. In conclusion, the Board finds that the Veteran is entitled to no more than a 30 percent rating, for service-connected tinea versicolor, from July 11, 2019. 2. Headaches Headaches are evaluated under Diagnostic Code 8100, 38 C.F.R. § 4.124a, which provides for a 10 percent disability rating for characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent rating is assigned for characteristic prostrating attacks occurring on an average once a month over the last several months. Finally, a 50 percent disability rating is assigned for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. VA regulations do not define “prostrating.” By way of reference, the Board notes that according to Webster’s New World Dictionary of American English, Third College Edition (1986), p.1080, “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in Dorland’s Illustrated Medical Dictionary 1554 (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” The Veteran stated he has headaches daily. See June 2009 Correspondence. The August 2009 VA examination report noted daily headaches and that most attacks are prostrating requiring the Veteran to be in a darkened secluded room with hot compressions, that they last up to 2 days, and that his headaches cause severe impact on usual daily activities. The December 2009 VA examination report noted headaches about two times a week that increase in intensity requiring rest for a few hours. The February 2016 VA examination report noted the Veteran has headaches all the time with prostrating attacks up to 2 times per month and that they last less than a day. The Veteran stated in a June 2016 notice of disagreement (NOD) that his headaches are continuous, he gets dizzy and has nausea and vomiting, and his headaches require him to use a cloth and be in a room completely dark. The Veteran stated he has headaches every day, which are severe up to 4 times a week. See October 2017 Veteran statement. The Veteran asserts he quit his job due to his headaches. See January 2019 Correspondence. The Veteran stated his intense headaches do not allow him to think. See January 2019 VA Form 21-8940. Vocational expert W.C.’s December 2018 assessment noted the Veteran’s service-connected headaches and fibromyalgia preclude him from being able to secure and follow a substantially gainful occupation. The July 2019 VA examination report noted the Veteran’s headaches impact his concentration and memory, last up to 2 days, and are prostrating once every month. A September 2019 private examination noted the Veteran’s headaches were aggravated by various physical activities, to include bending, standing, lifting, and sitting. In June 2020, the Veteran stated he does not understand English well and that the most recent VA examiner asked him questions, but he was unsure if he answered correctly, and that his headaches are daily, that never go away, and require him to lie down. Here, the evidence suggests the Veteran has multiple prostrating attacks a week that can last multiple days, which require him to lie down and do nothing, with symptoms such as vomiting. As such, the Veteran has very frequent completely prostrating and prolonged attacks. Medical evidence suggests the Veteran’s headaches impact his daily activities and limits his physical activities as well. Expert evidence suggests the Veteran’s headaches, in part, prevent him from obtaining gainful employment. The Veteran stated he quit his job, in part, due to his headaches. As such, the evidence suggests the Veteran’s headaches are productive of severe economic inadaptability. Overall, the Board finds the severity of the Veteran’s headaches more closely resemble the criteria for a 50 percent disability rating under Diagnostic Code 8100 for the entire appellate period. As such, the Veteran is entitled to a maximum 50 percent initial disability rating for headaches. Therefore, the Veteran’s service-connected headaches have been assigned the maximum schedular rating available for the entire rating period, the Board finds there is no legal basis upon which to award a higher schedular evaluation for his service-connected headaches. REASONS FOR REMAND The Board has granted service connection for an acquired psychiatric disorder and an overreactive bladder in the instant decision. These conditions have yet to be rated by the AOJ. As the initial ratings assigned for these conditions could significantly impact the outcome of the TDIU claim, the Board must defer adjudication of the TDIU claim until after the AOJ has had the opportunity to assign an initial rating for the disabilities the Board has service connected herein. The matter is REMANDED for the following action: 1. Assign an initial rating for the Veteran’s acquired psychiatric disorder and bladder condition and then readjudicate the issue of entitlement to TDIU considering all the evidence of record. 2. If the TDIU claim remains denied, the case should be returned to the Board, if otherwise in order. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Zheng, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.