Citation Nr: 21064621 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 18-49 565 DATE: October 21, 2021 ORDER Entitlement to an initial 70 percent rating, but not higher, for unspecified trauma related disorder is granted. Entitlement to a 30 percent rating, but not higher, for tension headaches is granted. REMANDED Entitlement to a compensable rating for right knee patellofemoral syndrome is remanded. Entitlement to a compensable rating for bilateral tinea pedis is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's unspecified trauma related disorder manifested in occupational and social impairment with deficiencies in most areas, and without total occupational and social impairment. 2. Throughout the period on appeal, the Veteran's headaches manifested with characteristic prostrating attacks occurring on an average once a month over the last several months, and without frequently completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating, but not higher, for unspecified trauma related disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.125, 4.126, 4.130, Diagnostic Code 9413. 2. The criteria for a 30 percent for tension headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from March 2003 to May 2011, to include service in Southwest Asia. These matters come to the Board of Veterans' Appeals (Board) on appeal from September 2016 and June 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Louisville, Kentucky. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ) of the Board in August 2020. A transcript of the hearing has been associated with the claims file. Additionally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability, prior to November 22, 2019, has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). In this regard, the Veteran and his representative have alleged that he is unable to secure and maintain substantially gainful employment as a result of his service-connected unspecified trauma related disorder. However, the Board notes that in an April 2020 rating decision, entitlement to a TDIU was granted, effective November 22, 2019; prior to November 22, 2019, the record reflects that the Veteran maintained full time employment. As such, a Rice claim for entitlement to a TDIU prior to November 22, 2019 is not raised. INCREASED RATING Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). 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 in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. The veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Unspecified Trauma Related Disorder The Veteran seeks a higher rating for his service-connected unspecified trauma related disorder. Specifically, the Veteran asserts that his service-connected unspecified trauma related disorder manifested in symptoms that rise to occupational and social impairment with deficiencies in most areas throughout the entire period on appeal. See Board hearing transcript, August 28, 2020. The Veteran reported symptoms such as an inability to control his psychiatric symptoms, unemployability, panic attacks prohibiting shopping or church, the avoidance of crowds, hypervigilance, anxiety and inability to appropriately interact with others. Id. The Veteran's unspecified trauma related disorder is rated as 30 percent disabling prior to June 20, 2018, and 50 percent thereafter under the General Rating Formula for Psychiatric Disabilities (General Formula). 38 C.F.R. § 4.130. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 30 percent rating is warranted if the disability is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, without routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9413. A 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material; forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if the disability is productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A schedular maximum 100 percent rating is warranted if the disability is productive of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the United States Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in December 2019. As such, the DSM-5 applies, and the GAF scores will not be considered. A review of the record reveals that the Veteran sought mental health treatment from VA and private treatment providers, as well as treatment for his other health needs. To the extent that the Veteran's treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. Turning to the evidence, the Veteran was afforded a VA examination in April 2016. At that time, the examiner found the Veteran's unspecified trauma related disorder manifested with occupational and social impairment due to mild or transient symptoms with decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran reported he was married and had three young children. He described current family relationships as close and stable. He described his usual social and recreational activities as decreased social interactions and outings, and that the Veteran would get more nervous to go out in public. He stated he did not stay in touch with anyone but his family. The Veteran was employed for five years, and denied any occupational role impairment. At the April 2016 VA examination, the Veteran described his current mental health related symptoms or concerns as frequently anxious, defined as feeling tense with trouble relaxing. He also reported periods of irritability, limited stress or frustration tolerance, some periods of excessive worrying and panic attacks in public places requiring him to leave which he described as 15 to 20 minute episodes of feeling like something bad would happen, agitation, sweating, increased heart rate. He reported feeling like people were watching him, that he was making excuses to avoid going to crowded places with his wife, that he experienced disrupted sleep, but generally sleeping sufficiently and occasional nightmares. Symptoms attributable to his unspecified trauma related disorder included anxiety, panic attacks that occur weekly or less often and chronic sleep impairment. Behavioral observations at the April 2016 VA examination showed that the Veteran presented on time, was casually dressed and seasonally appropriate, drove himself alone, was alert and that he was oriented to person, place, time and situation. Affect was found to be mildly anxious, affect and mood were congruent for context and setting and speech was spontaneous with amplitude, pace, and prosody normal. There was no evidence that the Veteran responded to internal stimuli and no overt delusions evident in the Veteran's expressed thoughts. The Veteran denied having any recent or acute suicidal or homicidal ideation, intent, and plans, in active or passive forms. Judgment appeared intact and overall, generally memory and concentration appeared intact during the interview. The Veteran was afforded a VA examination in June 2018. At that time, the examiner found the Veteran's unspecified trauma related disorder manifested with 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. The Veteran reported he currently lived with his wife and three children, and he got along well with them "most of the time," but would lose his temper on occasion. He stated he did not go out with his family often, and did not do well in public places. He stated he would experience paranoia with sweating, and stated he could not really participate in any social activities anymore. He stated he sometimes had contact with his sister and grandfather, and did not have much contact with extended family members. He did not have close friends, but would interact with people at work. He was employed as a corrections officer at a federal prison, and reported occasional panic attacks at work with temper problems, but it seemed acceptable because it was a prison. The Veteran stated he missed work on occasion for medical reasons and because he did not feel like working. He reported anxiety, panic symptoms, difficulty concentrating, irritability and a depressed mood, maybe a few times a month. He denied crying spells but reported feelings of worthlessness and hopelessness on occasion. He denied suicidal ideation, ongoing sleep disturbances, with approximately only three to four hours of sleep per night with initial and middle insomnia and episodic trauma reexperiencing symptoms. Symptoms attributable to his unspecified trauma related disorder at the June 2018 VA examination included a depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment and mild memory loss, such as forgetting names, directions or recent events. Disturbances of motivation and mood were also found to be attributable to his unspecified trauma. Behavioral observations showed that the Veteran was appropriately and casually dressed, alert and oriented in all spheres with psychomotor activity that was unremarkable. He was found to be cooperative, friendly with unremarkable thought process. Trauma reexperiencing symptoms as noted and he denied suicidal and homicidal ideation. Speech was within normal limits and perceptual abnormalities were not reported nor observed. A depressed mood was noted, affect was found to be appropriate, insight was found to be adequate and judgment was found to be adequate. A February 2019 VA treatment record indicates that the Veteran had reduced memory capacity, with noted memory lapses for recent and remote events. For example, he reported that his sister had given him banners for his return from deployment in 2008 but that he could not remember the event, among other examples. He also noted significant trauma related symptoms associated with events he witnessed during his deployment including intrusive thoughts or memories, hypervigilance, panic attacks, and increased anger and irritability. The Veteran reported his current mood was as "just kind of there," and believed things would not improve. He noted feeling angry much of the time, sleep disturbances, and other neurovegetative symptoms were noted. The Veteran reported he no longer had a relationship with his mother after marrying someone he disapproved of, divorced his wife in 2009 and married his current wife in 2011, and found difficulty finding enjoyment in previously enjoyed hobbies. The VA examiner noted that an assessment of the Veteran's mood and personality suggested some exaggeration of psychological distress, perhaps a cry for help, but noted that his sister had confirmed significant changes in his emotional, social, and cognitive functioning following the Veteran's deployment. A March 2019 VA treatment record that indicates that the Veteran reported that he had difficulty controlling his anger, that he had difficulty long-term and short-term memory, that he felt easily frustrated and that he got easily irritated. He stated he needed to make reminders for himself to remember things. His appetite was reported to be good and energy level was reported to be "ok" as he got five to six hours of asleep at night. He felt that his anxiety was well controlled overall and denied panic attacks. He denied suicidal and homicidal ideation and symptoms suggestive of psychosis. An October 2019 VA treatment record that indicates the Veteran described feeling like a failure and expressing feelings of hopelessness about his future. He stated he was "miserable" at work and wanted to retire early. An additional October 2019 VA treatment record that indicates the Veteran reported fleeting suicidal ideations of driving his car off of the road, but without intention or plan. He denied a history of suicide attempts. A December 2019 private psychiatric evaluation was also submitted. At that time, the Veteran reported psychiatric disturbances that included anxiety, depression, suicidal ideation, insomnia and reduction in short-term memory or ability to cope with pressures. He was currently involved in psychotherapy and took psychotropic medication to treat his symptoms. He had not had any contact with his mother in seven years following her remarriage to someone he disapproved of, and he was only in contact with one of his siblings. He reported he was close to his late father. The Veteran reported that he graduated high school and attended one year of college and that he passed his college courses but did not like the environment and decided to join the military. After leaving the military, he reported that he worked with his father in drilling before the prison system. He stated he did not have regular interactions with his friends and did not attend church or other organized activities. He stated he married his first wife after returning from Iraq, but divorced due to having conflicts. He had two children with his first wife and saw those children several times a year. He was married to his second wife and had a seven year old daughter with her. During his December 2019 clinical interview, the Veteran reported feeling depressed all of the time and anxious most of the time and the only time he did not feel anxious was when he was at home. He stated he did not sleep very well and generally slept four to five hours a night. He endorsed suicidal ideation without specific plans to harm himself currently. He reported he had previously made plans to commit suicide but did not do so for his wife and children. The Veteran reported historically drinking a lot of alcohol, however, he had moderated his alcohol intake after beginning psychotropic medication. The Veteran endorsed flashbacks and stated the medication helped decrease the intensity of his disturbing dreams. The Veteran was still working but estimated he was only present about 50 percent of the time; he explained he could not deal with the multiple pressures of his job. He had attempted working in different parts of the prison but was similarly affected in all positions. He described being depressed most of the time at work and added that panic attacks would occur when in larger groups. Behavioral observations at his December 2019 psychiatric evaluation showed the Veteran moved slowly, that he wore glasses, that his speech was understandable, that his hearing seemed undisturbed and that he was cooperative. The provider found that the Veteran did not appear grossly confused, that his thought processing was logical and that his mood was moderately depressed and his tone matched the content of the discussion. The private psychologist noted that the Veteran's testing results indicated a high level of distress with some potentially exaggerated severity of his symptoms. However, despite the possible exaggeration, the Veteran's responses were viewed by the psychologist as communicating the intense focus on his limitations and his inner turmoil that he experienced, and the Veteran likely lacked a sense of trust that others could understand him. The provider noted that such caused what amounts to distortions that reduce the clarity of the way he communicated his concerns. The psychologist opined that the Veteran was experiencing major levels of distress stemming from depression and anxiety, and that those concerns significantly reduced his ability to cope and manage stresses, leading to avoidance followed by increased depression and disturbance. In other words, the psychologist found that the Veteran was not able to manage the pressures he felt in adaptive ways and further exposure lead dynamically to more psychological turbulence. Therefore, the psychologist found the Veteran was not able to function in a safe, appropriate manner in highly stressful work environments, with appropriate and consistently supportive multi-modal interventions, he may be able to reach a better level of adjustment in three to five years. Finally, the psychologist opined that the Veteran's psychological conditions precluded him from being able to function safely and effectively in stressful, contentious work situations such as those encountered in a penitentiary; his depression and anxiety reduce his ability to cope adaptively and would worsen if he continued to be exposed to such situations at that time. The Veteran was afforded a VA examination in March 2020. At that time, the examiner diagnosed unspecified trauma related disorder and alcohol use disorder. The examiner found that it was not possible to differentiate what symptoms were attributable to each diagnosis because the Veteran reported continued binge drinking; alcohol abuse was known to cause psychiatric symptoms related to mood, sleep disturbance, and the like. Therefore, the Board will consider the impact of all psychiatric symptoms reported on the Veteran's occupational and social functioning. At that time, the Veteran reported he was currently married with three kids, and described his family relationships as "my wife is trying to understand me... I am fine with my daughter, and don't see my boys a whole lot..." and continuing problems with his temper. He described his current social functioning as not having friends, isolation at home, distrust of others, and did not like others. His recreational activities included a farm and taking care of his animals. At his March 2020 VA examination, the Veteran was unemployed, and had last worked in December 2019 as a federal correctional officer. He worked for 8.5 years, and stated he was having increasing anxiety, panic attacks, and irritability on the job. He also reported he was making mistakes at work, to include forgetting to lock doors. He stated he also "cussed [his] supervisor out," at work, and eventually was found unfit for duty by a psychologist. He was medically retired. The Veteran reported the following symptoms: reliving traumatic events via periodic nightmares, occurring three to five times a month, typically with insomnia after; awakening with autonomic arousal or agitation; intrusive recollections two to three times a week with derealization; intense physiological and psychological distress in presence of cues associated with traumatic events; persistent dysphoric mood; periods of intense agitation and anxiety associated with exposure to stimuli; periods of depression hallmarked by sadness, anhedonia, isolative behavior, loss of interest in usual activities, decreased libido, reduced motivation; periods of passive suicidal ideation, without plans, urges, or intent; ongoing irritability with limited stress-frustration tolerance; frequent anger outbursts; confrontational behavior without altercations; suspiciousness; hypersensitivity to safety issues; panic attacks; scanning behavior; easily startled; agitation around crowded public places; and poor sleep. Symptoms attributable to his unspecified trauma related disorder at the March 2020 VA examination included a depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often and chronic sleep impairment. Other symptoms attributable to his unspecified trauma related disorder included difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. Behavioral observations showed the Veteran presented on time for the appointment, that he was causally and seasonally appropriately dressed, that he appeared his stated age and drove alone. He was noted to be alert, that he was oriented to person, place, time, and situation, that his affect was dysphoric, that his affect and that his mood were congruent for context and setting. Speech was found to be spontaneous while amplitude, pace, and prosody were found to be normal today without evidence that the Veteran was responding to internal stimuli. No overt delusions evident in his expressed thoughts. He denied having any recent or acute suicidal or homicidal ideation, intent, or plan in active or passive forms. Judgment was found to be intact and overall general memory and concentration appeared intact during the interview. A May 2020 VA treatment record that indicates the Veteran described his mood as "drained," and a "3 out of 10." His appetite and energy level were reported to be good. He was coping fairly well with the COVID-19 pandemic. Overall, he felt that his depression and anxiety were manageable with medications, and denied side-effects. At his August 2020 Board hearing, the Veteran testified his psychiatric symptoms included unemployability, interference with his life on a daily basis, panic attacks in crowds and inability to go into public places. He also testified hypervigilance, having a "scrambled" brain, anxiety or panic attacks and the avoidance of others. He testified that he was isolated from family and only spoke to his siblings once a year. The Veteran testified that his daughter was afraid of him and would only talk to his wife because of his temper. He testified he had depression that would prevent him from accomplishing tasks and that caused marital conflicts because of his tendencies to isolate and lack of socialization with others. The Veteran stated he was no longer working, and that he had verbal altercations with coworkers and inmates due to his temper, and eventually he resigned after encouragement from his supervisors. He stated he initially tried to retire, but that it was not approved, and he resigned. The Veteran also testified that his wife had given up on making him join family or social events, but that she still did not like his lack of interactions. The Veteran testified that he needed to have everything in its place at home and was overly concerned with safety. He stated he was undergoing treatment, and that medication seemed to help his symptoms. He testified that his psychiatric symptoms impacted his employment and that he was unemployable. He testified regarding disrupted his focus and concentration, that he was isolated outside of his home to do welding and be alone and that he lost items and being lost or disoriented outside of his house. He also reported being verbally disciplined by his supervisors at work. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities, to include his unspecified trauma related disorder. However, there is no indication from the treatment notes of record that the Veteran has reported mental health symptoms that are worse than those noted above. Based on the foregoing, the Board notes that the Veteran has exhibited symptoms consistent with a 70 percent rating throughout the period on appeal as he has displayed deficiencies in most areas. Impairment to mood was demonstrated as the record reveals depressed mood, anxiety, difficulty concentrating, impaired sleep, social isolation, significant and severe panic attacks, inability to interact with others at work, and impaired familial relationships. Impairment to work was demonstrated as the Veteran reported difficulty or inability to continue working, and eventually resigned from his job due to the severity of his psychiatric symptoms. However, the Veteran was able to perform his duties as a federal corrections officer until November 2019, and indicated that some of his psychiatric symptoms were tolerated because of the prison environment. Some impairment to family relations was shown as the Veteran reported he had minimal social interaction, had significant anxiety and depressive symptoms, and had difficulty interacting or attending public gatherings. However, the Veteran consistently reported an "ok" relationship with his wife, enjoyed some hobbies, and was able to independently perform activities of daily living. He reported that his motivation and mood were negatively affected by his psychiatric functioning. No impairment to thinking was demonstrated. Judgment was not impaired as it was consistently found to be intact or good during the appeal period. School was not attempted during the appeal period. Additionally, the Veteran noted he was estranged from his mother and did not speak to some of his siblings; he also reported he divorced from his first wife as a result of his psychiatric symptoms. However, the Veteran maintained good contact with his children from his first marriage, and one of his siblings. The Veteran also indicated that he was estranged from his mother due to belief that she married a pedophile, and not as a result of his psychiatric manifestations. Therefore, the Board finds that the Veteran's psychiatric symptoms most closely approximated occupational and social impairment with deficiencies in most areas to warrant a higher 70 percent rating. A rating in excess of 70 percent is not warranted as total social and occupational impairment was not warranted. Total social impairment was not demonstrated as the Veteran maintained a relationship with his wife and children. Although the Veteran reported suicidal ideations, no suicidal attempts were noted and there is no evidence that the Veteran was a persistent danger of hurting himself or others. Additionally, there is no evidence or allegation that he was unable to maintain minimal personal hygiene. Mental status examinations during the appeal period consistently found the Veteran's grooming and hygiene to be appropriate or adequate. Although the Veteran reported difficulties with his memory, there is no evidence or assertion that he experienced memory loss for names of close relatives, own occupation or own name. There is no evidence or allegation that the Veteran's psychiatric symptoms manifested in interference or difficulties resulted in the inability to perform activities of daily life, to include maintenance of minimal hygiene. There is no evidence, and the Veteran has not alleged, gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, disorientation to time or place, Therefore, this is not a disability picture indicating total occupational and social impairment at any time during the appeal period. In assessing the severity of the unspecified trauma disorder, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support a rating higher than what was assigned here as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board has considered whether staged ratings under Hart, supra is appropriate; however, the Board finds that his symptomatology was been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. The Veteran nor his representative have not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence supports a 70 percent rating, but not higher, throughout the period on appeal; to that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Tension Headaches The Veteran seeks a higher rating for his service-connected tension headaches Specifically, the Veteran asserts that his service-connected tension headaches manifested in symptoms of sharp pain, like being hit with a hammer, an inability to focus, difficulty seeing; an upset stomach and required him to lay in bed and cover his head about once a month to once every other month. See Board hearing transcript, August 28, 2020. The Veteran testified he would have to take medication and would not be able to work on days when he had bad headaches. Id. The Veteran also testified he had less severe headaches a couple times a week, that he treated with medication and could go to work during those less severe episodes. Id. The Veteran's tension headaches are rated as noncompensable under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a noncompensable rating is warranted for less frequent attacks than as follows. 38 C.F.R. § 4.124a, Diagnostic Code 8100. A 10 percent rating is warranted where the disorder manifests with characteristic prostrating attacks averaging one in two months over the last several months. Id. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months. Id. A maximum 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. Governing case law and regulations have not defined "prostrating." For reference, the Board notes that "prostration" is defined as "extreme exhaustion or powerlessness." See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1531 (32d. ed. 2012). The use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met. Melson v. Derwinski, 1 Vet. App. 334 (1991); Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for a higher rating to be assigned). Here, each of the criteria listed in the 50 percent rating must be met in order to warrant a 50 percent rating. Tatum v. Shinseki, 23 Vet. App. 152 (2009). Turning to the evidence of record, the Veteran was afforded a VA examination in May 2017. At that time, the Veteran reported his headaches occurred at least once a week, lasting two hours in duration and experienced blurred vision and saw spots during the episodes. The Veteran's treatment plan included taking medication as needed. Symptoms of headache pain included constant head pain and pain on both sides of the head and non-headache symptoms included changes in vision. Typical duration of head pain was less than one day, and located on both sides of the head. The Veteran was not shown to have characteristic prostrating attacks of migraine or nonmigraine headache pain. The Veteran did not have very prostrating and prolonged attacks of migraines or nonmigraine pain productive of severe economic inadaptability. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's tension headaches did not impact his ability to work. The Veteran was afforded a VA examination in June 2018. At that time, the Veteran reported he continued to have headaches, about two or three times a week, and took over the counter medication for treatment. The Veteran's treatment plan included taking medication as needed. Symptoms of headache pain included pulsating or throbbing head pain and frontal headache and non-headache symptoms included sensitivity to light and sensitivity to sound. Typical duration of head pain was less than one day, and located on the front of his head. The Veteran was not shown to have characteristic prostrating attacks of migraine or nonmigraine headache pain. The Veteran did not have very prostrating and prolonged attacks of migraines or nonmigraine pain productive of severe economic inadaptability. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's tension headaches did not impact his ability to work. The examiner noted that the Veteran's typical day included working and farm chores, and he was not hindered by his headaches to the extent that he was unable to complete these tasks. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities, to include his tension headaches. However, there is no indication from the treatment notes of record that the Veteran has reported headache symptoms that are worse than those noted in the various VA examination reports of record. For the foregoing reasons, and resolving all doubt in favor of the Veteran, the Board finds that a 30 percent rating, but not higher, for tension headaches is warranted. In this regard, the Veteran was shown to have characteristic prostrating attacks occurring more than once a month. See Board hearing transcript, August 28, 2020. The Veteran testified that, approximately once a month, he experienced severe headache pain that required him to lay down and miss work. Id. In addition, he experienced less severe headaches that did not require him to lay down or miss work, occurring several times a week. In this case, the Board finds that the evidence demonstrates characteristic prostrating attacks that occur on an average of once a month over the last several months without very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability such that a 30 percent rating is warranted. After reviewing the totality of the evidence, therefore, and in consideration of the Veteran's subjective reports of migraine headache symptoms, the Board finds the criteria for a 30 percent rating, but no higher, have been met during the appeal period. The Board finds that a rating of 50 percent for his tension headaches is not warranted at any time during the period on appeal. In this regard, the Veteran was not shown to have migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Specifically, the May 2017 and June 2018 VA examination reports show the Veteran did not have very prostrating and prolonged attacks of migraines or non-migraine pain productive of severe economic inadaptability. In assessing the severity of the tension headaches, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, supra and Grottveit v. Brown, supra. However, the criteria needed to support a rating higher than what was assigned here as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, supra. As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board has considered whether a staged rating under Hart, supra, is warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. Further, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Accordingly, the Board finds that the preponderance of the evidence is for the assignment of a 30 percent rating, but not higher, for tension headaches; to that extent, the claim is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND Increased Rating Right Knee and Bilateral Tinea Pedis The Veteran was most recently afforded an examination for his right knee patellofemoral syndrome in June 2018 and for bilateral tinea pedis in December 2017. At his August 2020 Board hearing, it was indicated that the Veteran's right knee disorder and bilateral tinea pedis had worsened since his VA examinations. Specifically, with regard to his right knee disorder, the Veteran testified he experienced worsening pain, popping, giving out, weakness, feelings in instability, and required the use of a brace. Specifically, with regard to his bilateral tinea pedis, the Veteran testified that his skin symptoms had spread to his legs and were worse in colder weather. As the above evidence indicates a possible worsening of that the Veteran's right knee patellofemoral syndrome and bilateral tinea pedis since his last VA examination, an additional examination should be afforded to gauge the current level of severity of his disabilities. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA examination with an appropriate clinician(s) to determine the current nature and severity of his service-connected right knee patellofemoral syndrome. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran's service-connected right knee patellofemoral syndrome. The examiner should record the range of motion of the right knee on flexion and extension as observed on clinical evaluation in terms of degrees. The examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If there is clinical evidence of pain on motion, or any of the other above-noted symptoms, the examiner should indicate the degree of range of motion at which such pain begins, as well as whether such results in any loss of range of motion. The examiner should record the results of range of motion testing for pain on both active and passive motion, on weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case he or she should clearly explain why that is so. It is also imperative that the examiner comment on the functional limitations caused by flare-ups and repetitive use. In this regard, the examiner should indicate whether, and to what extent, the Veteran's range of motion is additionally limited during flare-ups or on repetitive use, expressed, if possible, in terms of degrees, or explain why such details cannot be feasibly provided. If the Veteran endorses experiencing flare-ups of his right knee patellofemoral syndrome, the examiner must obtain information regarding the frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups. if the examination is not being conducted during a flare-up, the examiner should provide an opinion based on estimates derived from the information above as to the additional loss of range of motion that may be present during a flare-up. If the examiner cannot provide an opinion as to additional loss of motion during a flare-up without resorting to mere speculation, the examiner must make clear that s/he has considered all procurable data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups elicited from the Veteran), but any member of the medical community at large could not provide such an opinion without resorting to speculation. The examiner should also comment as to whether (and if so, to what extent, (i.e., slight, moderate, or severe)) the Veteran's right knee patellofemoral syndrome results in recurrent subluxation or lateral instability. The examiner should also indicate whether there is dislocated or removed semilunar cartilage and, if so, the nature of the symptoms associated with such meniscus impairment. The examiner should comment upon the functional impairment resulting from the Veteran's right knee patellofemoral syndrome. A rationale for any opinion offered should be provided. 3. Following the receipt of outstanding records, schedule the Veteran for a VA examination with an appropriate clinician(s) to determine the current nature and severity of his service-connected bilateral tinea pedis. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran's service-connected bilateral tinea pedis. (Continued on the next page) A rationale for any opinion offered should be provided. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.