Citation Nr: 9918141 Decision Date: 06/30/99 Archive Date: 07/07/99 DOCKET NO. 94-29 690 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office & Insurance Center in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for hypertension as secondary to post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Pennsylvania Department of Military Affairs Bureau for Veterans Affairs and Assistance WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Michael J. Skaltsounis, Associate Counsel INTRODUCTION The veteran had active service from May 1966 to May 1968. Initially, the Board of Veterans' Appeals (Board) notes that this matter was previously remanded in January 1997 and April 1999 for evidentiary development and due process considerations. The Board finds that the Depart of Veterans Affairs (VA) Regional Office and Insurance Center (RO&IC) has accomplished the action requested in those remands to the extent possible, and that this matter is now ready for appellate consideration. FINDING OF FACT Hypertension is causally related to service-connected PTSD. CONCLUSION OF LAW Hypertension is proximately due to or the result of service- connected PTSD. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310 (1998). REASONS AND BASES FOR FINDING AND CONCLUSION Criteria Service connection may be established for a disability incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 1991). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1998). Service connection may be granted for a disorder which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). In Allen v. Brown, 7 Vet. App. 439 (1995), the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999, hereafter "the Court") held that the term "disability", as used in 38 U.S.C.A. § 1110, refers to impairment of earning capacity and that such definition mandates that any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, shall be service-connected. Thus, pursuant to 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.310(a), when aggravation of a veteran's nonservice-connected disorder is proximately due to or the result of a service-connected disability, such veteran shall be compensated for the degree of disability, but only that degree over and above the degree of disability existing prior to the aggravation. A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). The Court has also held that a determination with regard to entitlement to service connection must be made upon a review of the entire evidentiary record including thorough and comprehensive examinations that are representative of the entire clinical picture. Brown v. Brown, 5 Vet. App. 413 (1993). In this, and in other cases, only independent medical evidence may be considered to support Board findings. If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Moreover, it is the duty of the Board as the fact finder to determine credibility of the testimony and other lay evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). Lay persons are not competent to render testimony concerning medical causation. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service connection may be established through competent lay evidence, not medical records alone. Horowitz v. Brown, 5 Vet. App. 217 (1993). But a lay witness is not capable of offering evidence requiring medical knowledge. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board has the duty to assess the credibility and weight to be given the evidence. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992) (quoting Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), reconsideration denied per curiam, 1 Vet. App. 406 (1991)). Where there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). Factual Background Service medical records do not reflect complaints, treatments, or findings of any acquired psychiatric disorder, including PTSD, or hypertension. Blood pressure at entrance was noted to be 118/68, and at separation, 138/88. A Department of Veterans Affairs (VA) outpatient treatment record from August 1983 reflects that the veteran denied a history of hypertension or diabetes. In early September 1983 blood pressure was 130/90, and two weeks later, it was at 134/88. Service connection for PTSD was established and assigned a 10 percent evaluation in a rating decision in June 1986, based on service medical records and a VA examination in April 1986, which revealed a diagnosis of mild PTSD. Thereafter, the veteran filed a notice of disagreement with the initial rating for his PTSD, and in a February 1987 personal hearing, the veteran testified as to his PTSD symptoms. At this time, he did not offer testimony as to complaints or treatment for hypertension, nor did he relate such a condition to service or his PTSD. In a rating decision in June 1987, the evaluation for PTSD was increased to 30 percent, effective from February 1986. It was noted that VA examination in March 1987 revealed a diagnosis of significant PTSD. The RO&IC determined that results from a VA examination in May 1988 did not warrant a change in the 30 percent rating for the veteran's PTSD. A September 1988 outpatient record reflects that the veteran's blood pressure was slightly elevated at 130/98. In July 1989, blood pressure was at 134/92. A September 1989 outpatient record reflects that blood pressure was at 130/96, sitting, and when standing, 128/90. In October 1989, it was 120/86, and in December 1989, 130/90. A VA examination report from July 1990 reveals that the veteran reported a history of taking several medications in February 1990 for leg pain, and that he had a reaction to the medications, including high blood pressure. An August 1990 rating decision continued the 30 percent evaluation based on the results of this examination. VA outpatient records reflect that in August 1990, the veteran's blood pressure was at 148/84. In April 1991, the veteran's blood pressure was 124/86. In September 1991, there were readings of 163/100, 163/96, 146/92, and 124/42, and in October 1991, the veteran's blood pressure was at 156/93. In January 1992, blood pressure was at 142/94 and 144/84. In May 1992, it was at 130/94. In July 1993, blood pressure was at 134/80 and 120/88. In September 1993, the veteran applied for an increased rating based on complaints of an increase in stress and that his PTSD had worsened. A rating decision in January 1994 granted a temporary 100 percent rating due to hospitalization for PTSD, effective from November 1993. A November 1993 VA nursing note reflects that the veteran's blood pressure was at 160/100. In May 1994 the RO&IC increased the evaluation for PTSD to 50 percent, based on recent VA outpatient and hospital records, effective the month prior to the veteran's November 1993 hospitalization, and beginning once again in March 1994. In August 1994 the RO&IC continued the 50 percent evaluation based on a review of outpatient records over the period from May to July 1994. A June 1994 VA outpatient record revealed a blood pressure reading of 160/96. In July 1994, blood pressure was at 154/92. Additional August 1994 rating decisions and a September 1994 rating decision continued the 50 percent evaluation. A VA hospital summary from January 1995 reveals that during this hospitalization, the veteran experienced some transient but consistently increased diastolic blood pressure which Dr. A. found to probably be secondary to increased stress which he also encountered consistent with his PTSD, and also when he did not receive medication on time periodically. Thereafter, a March 1995 VA medical statement from Dr. G. reflects that the veteran had hypertensive vascular disease which was caused by his PTSD. Also, Dr. G. indicated that the PTSD served as a stressor for his hypertension; therefore, both conditions were related and both needed to be treated. In reviewing the veteran's recent hospital records at Philadelphia, Dr. G. found that the veteran's systolic blood pressures were as high as 178, and diastolic pressures as high as 98. Dr. G. further noted that the veteran had been seen in the cardiology clinic and that at present, he did have significant hypertension requiring treatment. A March 1995 discharge summary from B. Hospital reflects that the veteran had been under the care of the VA medical center for hypertension and PTSD, and that following recurrent left chest pain which had become very intense the night before, he was admitted to this facility and given Morphine. Blood pressure at the time of admission was 221/131. The diagnosis included hypertension and PTSD. A VA outpatient record from April 1995 reflects the medical opinion that hypertension could aggravate the veteran's PTSD which was an anxiety disorder. An April 1995 medical statement from Dr. G. again reflects that the veteran had hypertensive vascular disease which was caused by his PTSD, that PTSD served as a stressor for his hypertension; and that, therefore, both conditions were related and both needed to be treated. Recent diastolic pressures were noted to be as high as 100. Dr. G. planned to follow the veteran on a regular basis and to continue treatment. Dr. G. also referred to a study from the VA medical center in Charleston, South Carolina, entitled General Hospital Psychiatry, March 1994, Vol. 16, pp. 135 to 137, that pointed out that there could be an exacerbation of PTSD symptoms in a patient with concurrent medical illness including hypertension. Dr. G. also referred to a study found in The Journal of Neurology, November 1992, Vol. 42, pp. 2225 to 2226, which noted the high frequency of hemorrhagic strokes during the Persian Gulf War, with increased occurrences of hypertension and PTSD causing hemorrhagic stroke. PTSD and hypertension were combined to cause hemorrhagic strokes in thirty out of thirty-nine of the patients studied. VA medical examination in May 1995 revealed blood pressure readings of 120/72, 114/68, and 110/70. It was further noted that then-current medications of Procardia XL, Pravastatin, and Tenormin had been successful in maintaining well normalized blood pressure. Extremities revealed no edema. The impression was hypertension, well controlled with medication. Reference was made to hypertension recorded as far back as 1989. A May 1995 VA medical statement from Dr. G. reflects that a review of hospital records, inpatient and outpatient, from the Coatsville VA medical center and the Philadelphia VA medical center for the period of 1989 to 1995 revealed systolic blood pressures to vary from 150 to a high of 220, and diastolic pressures ranging from 100 to 130. The veteran had been followed by Dr. G. in the cardiology clinic, and it was noted that the veteran had hypertensive cardiovascular disease requiring treatment with Procardia XL and Tenormin. In any event, Dr. G. indicated that the veteran had significant hypertension requiring treatment with two medications. In addition, Dr. G. noted that he had been able to correlate an aggravation of PTSD symptoms secondary to the hypertension and conversely, an aggravation of his hypertension at times by his PTSD. Dr. G. again referred to the study in The Journal of Neurology, November 1992, Vol. 42, pp. 2225 to 2226, which noted that PTSD and hypertension were combined to cause hemorrhagic strokes in thirty out of thirty-nine patients studied, and Dr. G. believed that this obviously pointed out the relationship of the two conditions. Dr. G. also once again noted the results from the study from the VA medical center in Charleston, South Carolina, General Hospital Psychiatry, March 1994, Vol. 16, pp. 135 to 137. In an additional medical statement, dated in June 1995, Dr. G. went on to comment that the veteran had essential hypertension rather than hypertension as secondary to other pathology such as renal disease. He further noted that psychiatric issues and hypertension were discussed in Heart Disease, a Textbook of Cardiovascular Medicine, 1984, Vol. 2, Part 4, page 1834, wherein it was concluded that psychological conflicts and psychophysiologic mechanisms had been estimated as contributing substantially to the etiology of essential hypertension. Dr. G. indicated that this fact was also pointed out in a Textbook of Essential Hypertension, 1970, page 116, by H. Weiner. While Dr. G. went on to note that he had been unable to identify and specific studies that demonstrated that PTSD caused hypertension, he opined that stress was obviously a factor in the etiology of essential hypertension. Stress was also part of the PTSD syndrome and it certainly aggravated essential hypertension, and as noted above, others believed that it actually was a part of the etiology of essential hypertension. In summary, Dr. G. believed that the veteran had essential hypertension. He further believed that the veteran had significant stress which, as noted in the reference, could serve as an etiology for essential hypertension. PTSD certainly aggravated hypertension because of the stress and other features of the PTSD syndrome. Dr. G. had not identified specifically hypertension resulting from PTSD, but went on to conclude that the coexisting stress did form an etiology for essential hypertension. In the veteran's case, Dr. G. believed that when he was agitated and disturbed, his blood pressure had risen to significant levels and that this was well documented in the records. A physician's report based on various studies, received from the veteran's service representative by the RO&IC in October 1995, indicates that psychological stress played an important causative role in the development of hypertension and that veterans suffering from PTSD were at increased risk for developing hypertension. The report further indicates that hypertension might be the cumulative effect of years of stress and the body's response to it. In a remand in January 1997, the Board requested that the RO&IC obtain outstanding Social Security Administration (SSA) records, and also requested further medical opinions as to the whether PTSD caused identifiable additional disability with respect to the veteran's hypertension. VA medical examination in February 1997 revealed that there was a diagnosis of hypertension in 1989 and an initial diagnosis of PTSD in 1980. Blood pressure readings at this time were 140/72, 120/82, and 118/72. It was further noted that blood pressure readings in April 1995 were 120/70 in the right arm and 110/68 on the left. In November 1994, blood pressure was 120/80, and in June 1996, it was 126/76. The diagnosis was hypertension, controlled on medication, with no evidence of any organ damage at this time. It was this physician's opinion that hypertension could have been aggravated by the veteran's PTSD. By a rating decision in March 1997, the veteran's evaluation for PTSD was permanently increased to 100 percent, effective from September 1993. VA medical examination in September 1998 revealed that the veteran reported a history of an initial diagnosis of high blood pressure in 1989 and that he had been on two medications for this condition. When he stopped taking one of his medications in 1998 pursuant to doctor's orders, he noted the onset of headaches and elevated blood pressure. He was then advised to resume both medications. The veteran indicated that he experienced recurrent episodes of severe anxiety and emotional reaction to his high blood pressure and PTSD. He further related that he had been very concerned about his blood pressure and believed that if he was under stress, his blood pressure would rise. He was also concerned about having a problem on a long-term basis. At this time, blood pressure was 120/60 on the right, and 124/70 on the left. The diagnosis included essential hypertension without evidence of target organ damage. The examiner further commented that the veteran was documented to have hypertension some time ago, that this was controlled, and that the veteran had been advised that his hypertension was a stress-associated condition. The examiner believed that the blood pressure could be elevated under stress. The examiner went on to comment that hypertension was certainly a condition which could be aggravated by several factors. In regards to the veteran's disability, the examiner concluded that he had hypertension, that he also had PTSD and was very excitable, that his hypertension was aggravated under conditions of stress and by PTSD, and that PTSD could also be associated with high blood pressure. He concluded that the veteran hypertension certainly was aggravated by PTSD. In a December 1998 addendum to the September 1998 examination report, the examiner indicated that the veteran had essential hypertension and PTSD. He also noted that his hypertension was well controlled with medication. He further noted that PTSD was known to increase the blood pressure. However, while there was no evidence of target organ damage, his blood pressure was elevated. At this time, he could not attribute any disability produced by the veteran's hypertension. In a final addendum, dated in January 1999, the examiner concluded that there was no increased manifestation of the veteran's hypertension secondary to PTSD, that the veteran's blood pressure was well controlled with appropriate use of medication, that there was no manifestation of target organ damage due to hypertension, and that the need for regular use of blood pressure medication was necessary on an ongoing basis. At the veteran's hearing before a member of the Board in May 1999, the veteran testified that he had been service connected for PTSD since 1983 (transcript (T.) at p. 3). He further noted that his PTSD had worsened since 1983, and that this disability was currently rated as 100 percent disabling (T. at p. 3). He continued to have intrusive thoughts of Vietnam, and when he had such thoughts, his blood pressure would rise (T. at pp. 6-7). On one occasion, his blood pressure rose to 210/130 as a result of his PTSD (T. at p. 7). At that time, the veteran was given Morphine (T. at p. 7). The veteran believed that his blood pressure would rise in conjunction with and as a cause of his PTSD (T. at pp. 7- 8). He further indicated that the physician who conducted the VA examination at the Coatesville VA medical center in 1997 or 1998 believed that the veteran's PTSD exacerbated his hypertension and possibly even triggered it (T. at p. 8). This view was also reportedly shared by an examiner at the VA medical center in Wilmington approximately six months later (T. at p. 8). The worst episode was in 1994 (T. at p. 8). The veteran indicated that he had been told by one or more physicians that his service-connected disability was the causal effect for his hypertension (T. at p. 9). He went on to state that "everybody" concurred that his service- connected disability was causing the problem and that hypertension was, in fact, secondary to and as a direct result of PTSD (T. at p. 9). The veteran's spouse also believed that the veteran's hypertension was related to his PTSD (T. at p. 12). Analysis At the outset, the Board notes that at the time of the Board's previous remands, the Board found that under the case law, the veteran's claim must be regarded as well grounded under 38 U.S.C.A. § 5107(a) (West 1991), and that remand for further action was warranted. In this regard, the Board notes that the RO&IC obtained Social Security Administration (SSA) records, and provided the veteran with an additional medical examination and hearing before a member of the Board. Consequently, the Board finds that a reasonable effort has been made to comply with the requests set forth in the Board's remand and that in view of the Board's decision as set forth below, further remand of this matter for additional evidentiary development is not warranted. It is not claimed or otherwise shown that hypertension was present in or soon after separation from service. The contentions advanced in this case are related solely to an associative relationship between PTSD and hypertension. The Board also notes that the veteran's service-connected PTSD is now rated as 100 percent disabling, reflective of profound impairment from 1993. In this case, there is also rather compelling evidence that the worsening of the veteran's PTSD between 1989 and 1993 was contemporaneous with a similar rather dramatic increase in hypertensive symptomatology, and that this, in turn, was concurrent with the development of ongoing elevated blood pressure readings ultimately diagnosed as hypertension and requiring continual medication. While the opinions which acknowledge some relationship between hypertension and PTSD have most recently been followed by a VA medical opinion apparently finding no additional disability referable to the impact of the veteran's PTSD on the his hypertension under Allen v. Brown, supra (this will be discussed further below), the Board is impressed by the fact that the evidence supporting a direct relationship between PTSD and hypertension is essentially uncontradicted by any other physician whose opinion is of record. The tenets of Colvin v. Derwinski, supra, and other judicial mandates clearly preclude VA or the Board from unilaterally substituting its own opinion to the contrary based on its own judgment. Although the Board previously sought further development as to the issue of aggravation, the Board finds that a review of that evidence and critical evidence already of record leads to the conclusion that the veteran's hypertension is causally related to the veteran's PTSD. First, there is medical evidence offered by both Dr. G. and Dr. A., both of whom are treating physicians, that essential hypertension is related to the veteran's PTSD. More specifically, Dr. G. opines that stress from the PTSD contributed to the veteran's hypertension. In addition, Dr. A. in January 1995 notes a specific episode in which elevated blood pressure was related to PTSD. Finally, the Board notes that although its decision may seem to be inconsistent with the opinions of the most recent VA examiner, the Board finds that a close inspection of the examiner's opinions reveals that this is not the case. First, while the most recent examiner indicated that there was no increased manifestation of the veteran's hypertension secondary to PTSD, the Board observes that the examiner also noted the veteran's need for regular use of blood pressure medication on an ongoing basis. Thus, it is apparent that the examiner did not consider the fact that a history of diastolic pressure predominantly 100 or more or the requirement of continuous medication are representative of disability under the applicable rating criteria. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (1998). Therefore, the Board would infer that by acknowledging the need for continuous medication, the examiner acknowledged some measure of additional disability, and that further remand to confirm this interpretation in light of the physician's statements and other opinions of record is unnecessary and would be an unwarranted use of VA resources. In summary, the Board finds that while the findings are not universal or unequivocal in nature, the evidence is indeed consistently in equipoise with regard to an etiological and influential relationship between the veteran's PTSD and its ramifications, and hypertension; and that the benefit of the doubt under these circumstances must be resolved in the veteran's favor. Consequently, service connection for hypertension as secondary to service-connected PTSD is in order. ORDER Entitlement to service connection for hypertension as secondary to service-connected PTSD is granted. RONALD R. BOSCH Member, Board of Veterans' Appeals