Citation Nr: 21005625 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 12-27 312A DATE: February 2, 2021 ORDER Entitlement to an initial compensable rating for residuals of traumatic brain injury (TBI) from May 12, 2011 to December 16, 2016 is denied. Entitlement to an initial rating higher than 10 percent for residuals of TBI with vestibulopathy from December 16, 2016 to December 18, 2019 is denied. Entitlement to an initial rating higher than 10 percent for residuals of TBI with vestibulopathy from December 18, 2019 to February 4, 2020 is denied. Entitlement to an initial rating of 70 percent for posttraumatic stress disorder (PTSD) from October 28, 2010 to February 4, 2020, is granted, subject to controlling regulations governing the payment of monetary awards. FINDINGS OF FACT 1. From May 12, 2011 to December 16, 2016, the Veteran’s residuals of TBI subjective symptomatology most nearly approximates level “0” impairment based on symptoms that do not interfere with work. 2. From December 16, 2016 to December 18, 2019, the Veteran’s residuals of TBI with vestibulopathy resulted in occasional dizziness. 3. From December 18, 2019 to February 4, 2020, the Veteran’s residuals of TBI with vestibulopathy resulted in occasional dizziness. 4. From October 28, 2010 to February 4, 2020, the symptoms and impairment caused by the Veteran’s PTSD more nearly approximated occupational and social impairment with deficiencies in most areas but did not more nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. From May 12, 2011 to December 16, 2016, the criteria for an initial compensable rating for residuals of TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8045. 2. From December 16, 2016 to December 18, 2019, the criteria for an initial rating in excess of 10 percent for residuals of TBI with vestibulopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8045-6204. 3. From December 18, 2019 to February 4, 2020, the criteria for an initial rating in excess of 10 percent for residuals of TBI with vestibulopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8045. 4. From October 28, 2010 to February 4, 2020, the criteria for an initial 70 percent rating for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1968 to July 1970. These matters initially came before the Board of Veterans’ Appeals (Board) on appeal from an October 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which granted service connection for PTSD with an evaluation of 10 percent effective October 28, 2010 and granted service connection for residuals of TBI with a noncompensable evaluation effective May 12, 2011. That decision also granted service connection for tinnitus and denied service connection for hearing loss. In November 2011, the Veteran disagreed with the evaluations assigned to his service-connected PTSD and TBI, as well as the denial for service connection for hearing loss. However, he did not include the denial of service connection for hearing loss in his October 2012 appeal to the Board which pertained to only PTSD and TBI evaluations. The Board remanded the issues in November 2016 for new VA examinations. In a January 2017 rating decision, the RO increased the evaluation of PTSD to 50 percent effective December 16, 2016, and granted service connection for vestibulopathy under Diagnostic Code 6204 (previously rated under Diagnostic Code 8045 for residuals of TBI) at 10 percent effective December 16, 2016. In June 2018, the Board denied increased ratings for the Veteran’s PTSD and TBI vestibulopathy disabilities on appeal. The Veteran filed an appeal to the United States Court of Appeals for Veteran’s Claims (Court). In May 2019, the Veteran through private attorneys and VA though the Office of General Counsel filed a joint motion for remand (JMR). The Court granted the JMR that same month, vacating the June 2018 Board decision, and remanding the matter for additional proceedings consistent with the JMR. In October 2019, the Board remanded the case in accordance with the May 2019 JMR to obtain a medical opinion on whether the Veteran’s headaches are attributable to his TBI, and for an examination of the severity of the Veteran’s PTSD based on the DSM-IV specifically. In a November 2020 rating decision, the RO increased the evaluation of PTSD to 70 percent effective February 4, 2020. In that rating decision, the RO also found a clear and unmistakable error (CUE) in the January 2017 rating decision assigning a separate 10 percent evaluation assigned for vestibulopathy based on 38 C.F.R. §§ 4.14, 4.124a (pyramiding). Regarding the evaluation of PTSD, because an examiner stated it was not possible to differentiate what symptoms were attributable to TBI and any non-TBI mental health diagnosis, a symptom interaction and/or overlap is probable, effective February 4, 2020, the Veteran’s PTSD is evaluated with his TBI. The condition is rated using the PTSD criteria which is most advantageous to the Veteran. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations 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. In determining the severity of a disability, the Board is required to consider 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. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, it has been considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). Regarding the Veteran’s TBI disability evaluated on appeal, the Board agrees with the RO’s assignment of the three stages of ratings. Under Diagnostic Code 8045 for brain disease due to trauma, there are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment should be evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” See 38 C.F.R. § 4.124a, Diagnostic Code 8045. Subjective symptoms may be the only residual of TBI, or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, are evaluated under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, should be separately evaluated, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table. Id. Emotional/behavioral dysfunction is evaluated under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Id. Physical (including neurological) dysfunction is evaluated based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine the evaluations for each separately-rated condition under § 4.25. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Id. The need for special monthly compensation (SMC) is to be considered for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Id. The table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a fifth level, the highest level of impairment, labeled “total.” However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than “total,” since any level of impaired consciousness would be totally disabling. Assign a 100 percent evaluation if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. See 38 C.F.R. § 4.124a, Diagnostic Code 8045. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” with manifestations of a comorbid mental, neurologic, or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Id. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Id. Note (3): “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Id. Note (4): The terms “mild,” “moderate,” and “severe” TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Id. The words “mild,” “moderate,” and “severe” are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just.” See 38 C.F.R. § 4.6. Evaluations assigned are based upon the highest level of severity for any facet of cognitive impairment and other residuals of TBI not otherwise classified as determined on examination. Only one evaluation is assigned for all the applicable facets. A higher evaluation is not warranted unless a higher level of severity for a facet is established on examination. Physical and/or emotional/behavioral disabilities found on examination that are determined to be residuals of traumatic brain injury are evaluated separately. Id. As an initial matter, as per the May 2019 JMR and October 2019 Board remand, the RO obtained a medical opinion regarding a potential relationship between headaches and the Veteran’s service-connected TBI disability due to conflicting evidence in the claims file regarding the onset of the headaches. In a January 2020 VA opinion, a VA physician opined that the Veteran’s headaches were less likely than not proximately due to or the result of the Veteran’s service-connected condition. Noting she had reviewed all pertinent medical records and the October 2019 remand, and citing to the Veteran’s attorney’s remark that a 2016 examiner mentioned a history of headaches beginning 10 years prior to that 2016 evaluation, the January 2020 VA physician wrote that whether the Veteran’s headaches began two or ten years prior to evaluation was irrelevant. A 37-year interval between the injury and the onset of functionally incapacitating headaches is simply too long to suggest that there is a causal relationship between the two events. Therefore, based on her thorough review of records, detailed history and clinical examination, she found that it was less likely than not that the Veteran’s headache complaints are a residual of his TBI. This opinion is highly probative as it was provided by a qualified medical professional who reviewed the entire record and provided detailed and thorough explanations for their positive medical opinions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008) (value of medical is found within its rationale). The December 2016 VA examiner had also included in the examination report that headaches, memory loss, and neurobehavior symptoms occurred remotely from the TBI and are not likely associated with it, and that worsening neurobehavior symptoms may be associated with the Veteran’s mental health condition. Therefore, the Veteran’s non-service-connected headaches will not be considered as related to the Veteran’s service-connected TBI. 1. Initial compensable rating for residuals of TBI from May 12, 2011 to December 16, 2016. Based on the evidence of record, an initial compensable rating for service-connected residuals of TBI is not warranted from May 12, 2011 to December 16, 2016. The Veteran submitted a statement in support of claim in March 2012 in which he described his PTSD and TBI symptoms together. In the statement, he wrote that after returning from Vietnam, he did not reconnect with many of his old friends, he withdrew and started living a different life as his old friends seemed immature and he had little in common with them anymore. He also had some disagreement with his siblings and at the time of the March 2012 statement, had not had any contact with them in over 15 years. Regarding employment, he acknowledged that his PTSD and TBI may not have seriously affected his ability to remain employed, but has extremely limited his ability to socialized with supervisors, fellow employees, and clients, as well as affects his overall job performance and chances for promotion. In social relationships, the Veteran wrote he did not seem capable of making new friends and had not had any marriage or intimate relationships in 12 years. Sleep was also irregular, and he experienced anxiety. The totality of the medical evidence during this time shows the Veteran has been noted to be calm, alert, stable, oriented, having clear and concise speech with normal rate and tone, good eye contact, good hygiene remaining attention, and having a mental status within normal limits. See e.g. March 2012 PTSD Focus Group Visit; General Psychiatry Attending Notes from August 2012, December 2012, April 2013. He was alert and oriented with normal rate and tone of speech, good hygiene, good eye contact, goal-directed thoughts, and with insight and judgment intact. See August 2012 General Psychiatry Attending Note. Insight and judgment were fair and intact on multiple occasions during this appeal period. See February 2015 General Psychiatry Attending Note. In a September 2011 VA examination, it was documented that the Veteran described incidents of motion sickness and feels dizzy on occasions where he must travel or if he were to go on an amusement park ride. He attributed his own sleep problems to his PTSD. He had not hypersensitivity to sound or light, the Veteran’s judgement, motor activity without praxis, visual spatial, and orientation were all normal. The September 2011 VA examiner wrote no subjective symptoms interfere with work or activities other than the motion sickness, and no neural behavioral effects seriously interfered with work. The Veteran was able to communicate well, had a normal level of consciousness, and was competent to handle his financial affairs. There was no memory impairment, the Veteran had normal concentration attention and executive function, normal speech, and normal mobility and balance. Motor function testing resulted in strength of 5 over 5. Sensory function was normal. Vestibulopathy was diagnosed as secondary to TBI. These symptoms and residuals most nearly approximate a level of severity of “0” considering the facets of memory, attention, concentration, executive functions; judgment; social interaction; orientation; motor activity; visual spatial; subjective symptoms; neurobehavioral effects; communication; and consciousness. The evidence reflects that the Veteran’s subjective symptoms of TBI included vestibulopathy and situational dizziness, but with no serious interference of ability to work. A “0” is assigned for memory, attention, concentration, executive functions facet. For a “1,” mildly impaired judgment would have to be seen. A “0” is assigned for the judgment facet as that numeral represents normal, which was shown upon examination. For a “1,” mildly impaired judgment would have to be seen. A “0” is assigned for the social interaction facet as that numeral represents normal, which was shown upon examination. For a “1,” mildly impaired judgment would have to be seen. A “0” is assigned for the orientation facet, as the evidence indicates Veteran is oriented in all spheres. Occasional disorientation for a “1” is not shown. Motor activity also is assigned a “0” as this is normal. Motor activity that is normal “most” of the time is not demonstrated, so a “1” is not appropriate. A “0” is assigned for visual spatial orientation in that such appears normal. For a “1,” the Veteran would have to exhibit mild impairment, such as getting lost in unfamiliar surroundings, have difficulty reading maps or following directions, and use a GPS system. There is no indication of mild spatial impairment in the evidence of record. A “0” is assigned for neurobehavioral effects in that the Veteran has one or more neurobehavioral effects that do not interfere with workplace interaction. There is no indication that the Veteran’s neurobehavioral effects occasionally interfered with work-place interactions, social interactions, or both, but did not preclude them, so as to warrant a “1.” A “0” is assigned with communication, as there is no evidence of record which indicates that the Veteran is unable to communicate by spoken and written language, or comprehend spoken and written language. The Veteran does not warrant a “total” rating for consciousness, as there is no evidence which suggests that he is in a persistently altered state of consciousness, such as vegetative state, minimally responsive state, or in a coma. Based upon the foregoing, an initial compensable rating for the Veteran’s service-connected residuals of TBI from May 12, 2011 to December 16, 2016 is not warranted. See 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.159, 3.921, 4.1-4.16, 4.14, 4.124a, Diagnostic Code 8045. 2. Initial rating higher than 10 percent for residuals of TBI with vestibulopathy from December 16, 2016 to December 18, 2019. Based on the evidence of record, an initial rating in excess of 10 percent for service-connected residuals of TBI with vestibulopathy is not warranted from December 16, 2016 to December 18, 2019. At a December 2016 VA examination, the Veteran was diagnosed with TBI and vestibulopathy attributable to TBI. The Veteran complained that his dizziness had worsened, and of experiencing mild memory loss in that he was forgetful, which had been ongoing for the past 10 years and getting progressively worse. Upon examination, it was determined his judgment was normal, social interaction was routinely appropriate, he was always oriented to person, time, place, and situation, motor activity and visual spatial orientation was normal, there were no subjective symptoms, he was able to communicate by spoken and written language and to comprehend spoken and written language, and consciousness was normal. The December 2016 VA examiner did note under neurobehavioral effects that the Veteran has anger and anxiety for the past 20 years that is getting worse. Residuals of TBI were dizziness/vertigo, with no other pertinent findings. Regarding the ability to work, the Veteran experienced occasional unsteadiness and using the handrail when symptoms occur. The VA examiner found that headaches and memory loss occurred remotely from TBI and are not likely associated with it, and neurobehavior symptoms also occurred remotely and are not typically from TBI. These symptoms and residuals most nearly approximate a level of severity of “0” for the remaining facets of memory, attention, concentration, executive functions; judgment; social interaction; orientation; motor activity; visual spatial; neurobehavioral effects; communication; and consciousness. A “0” is assigned for memory, attention, concentration, executive functions facet. Though the Veteran reported a complaint of memory at the December 2016 VA examination, the examiner found that memory loss occurred remotely from TBI. For a “1,” mildly impaired judgment would have to be seen as caused by the TBI. A “0” is assigned for the judgment facet as that numeral represents normal, which was shown upon examination. For a “1,” mildly impaired judgment would have to be seen. A “0” is assigned for the social interaction facet as that numeral represents normal, which was shown upon examination. For a “1,” mildly impaired judgment would have to be seen. A “0” is assigned for the orientation facet, as the evidence indicates Veteran is oriented in all spheres. Occasional disorientation for a “1” is not shown. Motor activity also is assigned a “0” as this is normal. Motor activity that is normal “most” of the time is not demonstrated, so a “1” is not appropriate. A “0” is assigned for visual spatial orientation in that such appears normal. For a “1,” the Veteran would have to exhibit mild impairment, such as getting lost in unfamiliar surroundings, have difficulty reading maps or following directions, and use a GPS system. There is no indication of mild spatial impairment in the evidence of record. A “0” is assigned for neurobehavioral effects in that the Veteran has one or more neurobehavioral effects that do not interfere with workplace interaction. There is no indication that the Veteran’s neurobehavioral effects occasionally interfered with work-place interactions, social interactions, or both, but did not preclude them, so as to warrant a “1.” Additionally, the December 2016 VA examiner noted that his neurobehavioral effects were not likely attributable to TBI. A “0” is assigned with communication, as there is no evidence of record which indicates that the Veteran is unable to communicate by spoken and written language, or comprehend spoken and written language. The Veteran does not warrant a “total” rating for consciousness, as there is no evidence which suggests that he is in a persistently altered state of consciousness, such as vegetative state, minimally responsive state, or in a coma. The Veteran does not warrant a “total” rating for consciousness, as there is no evidence which suggests that he is in a persistently altered state of consciousness, such as vegetative state, minimally responsive state, or in a coma. The evidence reflects that the Veteran’s subjective symptoms of TBI included vestibulopathy and motion sickness. Considering the Veteran’s motion sickness/dizziness had worsened, the Board would agree with the RO’s assignment of a 10 percent evaluation based on occasional dizziness under Diagnostic Code 6204 Peripheral vestibular disorders, as a residual of TBI for this period on appeal. See January 2017 rating decision. The result of the 10 percent rating would remain unchanged. Based upon the foregoing, an initial rating in excess of 10 percent for the Veteran’s service-connected residuals of TBI with vestibulopathy from December 16, 2016 to December 18, 2019 is not warranted. See 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.159, 3.921, 4.1-4.16, 4.14, 4.124a, Diagnostic Code 8045-6204. 3. Initial rating higher than 10 percent for residuals of TBI with vestibulopathy from December 18, 2019 to February 4, 2020. The Court has interpreted 38 U.S.C. § 1155 as implicitly containing the concept that the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology; such a result would overcompensate the claimant for the actual impairment of earning capacity and would constitute pyramiding of disabilities, which is cautioned against in 38 C.F.R. § 4.14. Essentially, under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the “same disability” or the “same manifestation” under various diagnoses is to be avoided. The Court held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the Veteran is entitled to separate ratings for different problems or residuals of an injury such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. Here, some of the Veteran’s symptoms for residuals of TBI overlap with his symptoms of his service-connected PTSD, such that to rate him under both the criteria for TBI under Diagnostic Code 8045 and PTSD would constitute pyramiding. Thus, as explained in the November 2020 rating decision, the Veteran’s previous compensable ratings awarded for TBI in the January 2017 rating decision were CUE, and the separate evaluation for TBI has ceased and TBI is now coupled with the rating for PTSD from February 4, 2020. From December 18, 2019 to February 4, 2020, an initial rating in excess of 10 percent for service-connected residuals of TBI with vestibulopathy is not warranted. The Veteran submitted a January 2020 privately-conducted Cognitive Screening for TBI without mental examination. The private examiner noted there was objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. Judgment was mildly impaired, and it was noted that the Veteran sometimes could not decide which road to take when driving. Social interaction was occasionally inappropriate in that the Veteran lived alone in a remote area and avoided crowds. Regarding orientation, the January 2020 private examiner found the Veteran was occasionally disoriented to time and place such as sometimes confused as to what day of the week it was and he did not know the name of the clinic for the appointment he was currently being assessed at. Motor activity was normal. Visual spatial was noted as being mildly impaired in that he reported having mild trouble reading a map. Subjective symptoms included occasional headaches, tinnitus, arthritis, and something pertaining to his PTSD. Neurobehavioral effects included irritability/belligerence, decreased empathy, and decreased flexibility. The examiner recorded that the Veteran had an inability to communicate or comprehend more than occasionally but less than half of the time due to being a slow reader and unable to think of a word. Consciousness was normal. Under cognitive dysfunction, the private examiner wrote that his symptoms can also be explained by his other diagnosed conditions of PTSD and Major Depressive Disorder. At a January 2020 VA examination, the Veteran was diagnosed with TBI and vestibulopathy attributable to TBI. The VA examiner wrote she concurred with the January 2020 private examiner in finding that a number of the Veteran’s symptoms are related to a psychiatric disorder. She also concurred and included subjective symptom of lack of judgment, problems with social interaction, and some of the neurobehavioral symptoms, but the VA examiner also added apportionment. She noted that his neurocognitive symptoms commenced only two years ago and she suspected they are correlated with his sleep disorder, and some of the neurobehavioral symptoms were attributed to his sleep apnea as well. The January 2020 VA examiner wrote that the Veteran has a vestibulopathy that produces imbalance and particularly in conjunction with his peripheral neuropathy poses a real risk for falls. Dizziness/vertigo was not diagnosed, but gait, coordination, and balance were . As explained above, the Veteran’s rating for TBI is currently combined with his service-connected PTSD, as medical examiners have attributed his symptoms as occurring from his psychiatric disability and in consideration of anti-pyramiding under 38 C.F.R. § 4.14. This is to afford him the highest rating available. He is currently rated at 70 percent for his PTSD with residuals of TBI from February 4, 2020. Prior to February 4, 2020, the Veteran’s PTSD was rated at 50 percent. The evidence reflects that the Veteran’s subjective symptoms of TBI included residuals of disabling vestibulopathy. Under the rating criteria for ears, vestibulopathy allows for a 10 percent rating for occasional dizziness. See 38 C.F.R. § 4.87 (Schedule of ratings – ear, Peripheral vestibular disorders). Considering the facets of memory, attention, concentration, executive functions; judgment; social interaction; orientation; motor activity; visual spatial; neurobehavioral effects; communication; and consciousness, the Veteran’s residuals of TBI symptoms during this period continue to most nearly approximate a level of severity of “0”. A “0” is assigned for memory, attention, concentration, executive functions facet. For a “1,” mildly impaired judgment would have to be seen as caused by the TBI. A “0” is assigned for the judgment facet as that numeral represents normal, which was shown upon examination. For a “1,” mildly impaired judgment would have to be seen as due to his TBI. A “0” is assigned for the social interaction facet as that numeral represents normal. For a “1,” mildly impaired judgment would have to be seen as due to his TBI, and both January 2020 examiners attributed his symptoms to his service-connected psychiatric disability. A “0” is assigned for the orientation facet, as the evidence indicates Veteran is oriented in all spheres. Occasional disorientation for a “1” is not shown due to his TBI. Motor activity also is assigned a “0” as this is normal. Motor activity that is normal “most” of the time is not demonstrated, so a “1” is not appropriate. A “0” is assigned for visual spatial orientation in that such appears normal. For a “1,” the Veteran would have to exhibit mild impairment, such as getting lost in unfamiliar surroundings, have difficulty reading maps or following directions, and use a GPS system. Though the private examiner noted he had mild trouble reading a map and sometimes could not decide which road to take, she also attributed his symptoms to his PTSD. A “0” is assigned for neurobehavioral effects in that the Veteran has one or more neurobehavioral effects that do not interfere with workplace interaction. There is no indication that the Veteran’s neurobehavioral effects occasionally interfered with work-place interactions, social interactions, or both, but did not preclude them, so as to warrant a “1.” A “0” is assigned with communication, as there is no evidence of record which indicates that the Veteran is unable to communicate by spoken and written language, or comprehend spoken and written language due to his TBI. The Veteran does not warrant a “total” rating for consciousness, as there is no evidence which suggests that he is in a persistently altered state of consciousness, such as vegetative state, minimally responsive state, or in a coma. The Veteran does not warrant a “total” rating for consciousness, as there is no evidence which suggests that he is in a persistently altered state of consciousness, such as vegetative state, minimally responsive state, or in a coma. Based upon the foregoing, an initial rating in excess of 10 percent for the Veteran’s service-connected residuals of TBI with vestibulopathy from December 18, 2019 to February 4, 2020 is not warranted. See 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.159, 3.921, 4.1-4.16, 4.14, 4.124a, Diagnostic Code 8045. The Board has considered the Veteran’s claim and decided entitlement based on the evidence. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (the Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if “§ 3.321(b)(1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board” (quoting Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff’d, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). PTSD The Veteran's PTSD is rated under 38 C.F.R. § 4.130, DC 9411. This disability is rated according to the General Rating Formula for Mental Disorders (General Rating Formula). Under the General Rating Formula, a 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such 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 [*14] (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Under the General Rating Formula, the Board must conduct a holistic analysis that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). In the January 2021 appellate brief, the Veteran’s representative noted that the Veteran’s PTSD rating has been staged and that, although staged ratings are appropriate when the symptoms and impairment vary during the pendency of the claim, Fenderson v. West, 12 Vet. App. 119 (1999), the symptoms and impairment did not change on the date of a particular VA examination and the level of the disability has been relatively consistent throughout the appeal. The Board agrees. May 2010 VA treatment notes show severe PTSD with isolation and no close relationships and deficiencies in most areas and those symptoms and impairment have been noted throughout the appeal period. Consequently, an initial 70 percent rating is warranted from the October 28, 2010 effective date of the grant of service connection. The Board also notes the rule regarding stabilization of ratings, which directs rating officials to effect the “greatest degree of stability of disability evaluations” when faced with fluctuating conditions. Tatum v. Shinseki, 23 Vet. App. 152, 158 (2009) (quoting 38 C.F.R. § 3.344). The appellate brief appears to indicate that the 70 percent rating is sought throughout the appeal period, but in any event the evidence shows some social and occupational activity throughout and therefore the symptoms and impairment have not more nearly approximated the total occupational and social impairment required for a 100 percent rating. To the extent that the grant of an initial 70 percent rating for PTSD affects the TBI rating, the grant of the initial 70 percent rating is subject to the controlling regulations governing the payment of monetary awards and it is expected that the agency of original jurisdiction will implement the grant in the manner most favorable to the Veteran and consistent with the applicable rating criteria. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Kuczynski, 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.