Citation Nr: 0010958 Decision Date: 04/26/00 Archive Date: 05/04/00 DOCKET NO. 93-11 898 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for residuals of a compression fracture of the back. 2. Entitlement to service connection for obesity, claimed as secondary to service-connected post traumatic stress disorder. 3. Entitlement to service connection for sleep apnea, claimed as secondary to service-connected post traumatic stress disorder. 4. Entitlement to an initial evaluation greater than 50 percent for post traumatic stress disorder. 5. Entitlement to an increased rating for nummular eczema, currently evaluated as 30 percent disabling. 6. Entitlement to an increased rating for residuals of shell fragment wound to the left hip with retained foreign bodies, currently evaluated as 10 percent disabling. 7. Entitlement to an increased rating for residuals of shell fragment wound to the right hip, thigh, and buttock, with retained foreign bodies, currently evaluated as 10 percent disabling. 8. Entitlement to a compensable rating for residuals of shell fragment wound to the left back. 9. Entitlement to a compensable rating for residuals of shell fragment wound to the right arm. 10. Entitlement to a compensable rating for hemorrhoids. 11. Entitlement to a total rating based upon individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Hickey, Counsel INTRODUCTION The veteran had active service from October 1963 to October 1968. This appeal to the Board of Veterans' Appeals (Board) arises from the May 1988 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York which denied evaluations in excess of 10 percent for residuals of shell fragment wound to the left hip with retained foreign bodies, and residuals of shell fragment wound to the right thigh and hip with retained foreign bodies, and for dermatitis of the left foot and ankle. In March 1989 the veteran withdrew his appeal of the May 1988 denial of increased rating for his service-connected skin disorder. The appeal also arises from the October 1989 rating decision of the RO in Newark, New Jersey, which granted service connection for post traumatic stress disorder (PTSD) evaluated as 30 percent disabling, and denied compensable ratings for the residuals of shrapnel wounds of the left back and right upper arm. The October 1989 rating action also denied entitlement to service connection for the residuals of a fracture of the lumbosacral spine claimed as secondary to the shrapnel wound of the left back. The appeal also arises from the April 1991 rating decision which denied service connection for obesity, claimed as secondary to service-connected PTSD, and the November 1992 rating decision which denied service connection for sleep apnea, claimed as secondary to service-connected PTSD. In January 1994 the RO increased the evaluation of PTSD to 50 percent. Finally, the appeal arises from the August 1995 rating decision which denied a compensable evaluation for service-connected hemorrhoids, and a rating greater than 30 percent for service-connected skin disability, and also denied the veteran's claim of entitlement to a total rating based upon individual unemployability due to service- connected disability. The record reflects that the veteran has raised several additional claims of entitlement to service connection for disabilities of the left chest, left arm, left thigh, alcohol abuse claimed as secondary to PTSD and disabilities of the bilateral knees and feet, claimed as secondary to PTSD, as well as service connection for pancreatitis and paragraph 29 benefits for hospitalization related to that disorder. It is also noted that in June 1994 the veteran claimed that a clear and unmistakable error had occurred in the original rating decision, with regard to the evaluation of disabilities of the right arm and upper left back. Inasmuch as those issues have not been adjudicated by the agency of original jurisdiction and are not "inextricably intertwined" with the issues currently on appeal, they will not be addressed herein, but are referred to the RO for appropriate action. FINDINGS OF FACT 1. The record reflects medical evidence of debilitating obesity. 2. VA medical evidence shows that the veteran's obesity results from compulsive overeating caused by his service- connected PTSD. 3. The record reflects private and VA medical evidence of moderate obstructive sleep apnea. 4. The record reflects a private medical opinion indicating that the veteran's obesity is partially or completely responsible for the veteran's propensity to sleep apnea. 5. Service medical records reflect that the veteran sustained a shell fragment wound to the back. 6. The record reflects current medical evidence of degenerative joint disease of the lumbar spine. 7. Current VA medical evidence reflects a diagnosis of remote injury to the back with a report of a fracture having occurred in 1965, with some degenerative disease in the lumbar spine. 8. Post traumatic stress disorder is productive of unemployability since the time of the veteran's resignation of employment. 9. Prior to his resignation of employment PTSD was manifested by difficulty in adapting to stressful circumstances such as his workplace, judgment impaired under stress, significant depression and psychoneurotic symptoms resulting in reduced efficiency levels and considerable industrial impairment. CONCLUSIONS OF LAW 1. The grant of service connection is warranted for obesity as proximately due to or the result of service-connected PTSD. 38 C.F.R. § 3.310(a)(1999). 2. The claim of entitlement to service connection for sleep apnea as proximal to service-connected PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310; Jones v. Brown, 7 Vet.App. 134 (1995). 3. The claim of entitlement to service connection for residuals of compression fracture of the lumbar spine is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). 4. Prior to the veteran's resignation of employment post traumatic stress disorder was not more than 50 percent disabling in accordance with any applicable schedular criteria. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, and 4.132, Code 9411 (1996), and 4.130, Code 9411 (1999). 5. Post traumatic stress disorder is 100 percent disabling since the veteran's resignation of employment. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, and 4.132, Code 9411 (1996). 6. The claim for a total rating based upon individual unemployability due to service-connected disability, as it applies to the period after the effective date of the assignment of a schedular 100 percent rating for PTSD , lacks legal merit. 38 U.S.C.A. § 4.16 (1999); Sabonis v. Brown, 6 Vet.App. 426 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service Connection Claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1153 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Disability which is proximately due to or the result of a service connected disease or injury also shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (1998). This regulation has also been interpreted by the Court to apply to those situations where a nonservice connected disability is being aggravated by a service connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied, 524 U.S. 940 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C. § 5107(a), the Department of Veterans Affairs (VA) has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the United States Court of Appeals for Veterans Claims (Court) issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Once a claimant has submitted evidence sufficient to justify a belief by a fair and impartial individual that a claim is well-grounded, the claimant's initial burden has been met, and VA is obligated under 38 U.S.C. § 5107(a) to assist the claimant in developing the facts pertinent to the claim. Accordingly, the threshold question that must be resolved in this appeal is whether the appellant has presented evidence that the claim is well grounded; that is, that the claim is plausible. In order for a claim to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Epps, 126 F.3d at 1468; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). With regard to secondary service connection a well-grounded claim requires competent medical evidence of a causal relationship between the service-connected disability and the nonservice-connected disorder. Jones v. Brown, 7 Vet.App. 134 (1995). Where the determinative issue involves medical causation or etiology, or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Epps, 126 F.3d at 1468. Further, in determining whether a claim is well- grounded, the supporting evidence is presumed to be true and is not subject to weighing. King v. Brown, 5 Vet.App. 19, 21 (1993). The medical evidence in this case reflects that the veteran suffers from debilitating obesity. At his July 1993 personal hearing at the Newark RO, the veteran testified that the condition interfered with ambulation, stair climbing, or even getting in and out of a vehicle "or just opening and closing his hip." He also noted shortness of breath and swelling in the lower extremities which the veteran attributed to his obesity. The record shows that when disability benefits were awarded by the Social Security Administration (SSA) in June 1994, the primary diagnosis listed was obesity, with PTSD also listed as the secondary diagnosis. A VA medical statement dated in February 1991 reflects that the veteran was in treatment for PTSD. In the opinion of the veteran's physician, he had a 25 year history of insomnia as a direct result of his service-connected condition for which compulsive eating has become associated as a secondary condition, leading to the veteran's obesity. It was reported that he overate markedly due to anxiety, tension and insomnia, and his participation in several weight loss programs had failed to provide any results. In view of this medical opinion linking the disabling condition to the service-connected psychiatric disability, the evidence reflects a plausible claim for secondary service connection for obesity as proximal to PTSD. Moreover, additional evidence shows that in August 1994 the veteran's treating psychotherapist reported that the veteran overate huge amounts of food because he was depressed and unable to sleep. In the absence of any evidence to the contrary, the evidence cited above supports the conclusion that the veteran's service-connected psychiatric disability is the cause of his disabling obesity. Accordingly service connection is warranted for obesity as secondary to PTSD. Also of record is medical evidence, both VA and private, reflecting moderate obstructive sleep apnea demonstrated on studies conducted in May 1991 to June 1991. In a July 1991 report the private medical doctor and psychologist who conducted the tests which resulted in this diagnosis, opined that significant weight reduction would lead to a partial or complete relief of the veteran's propensity to apnea. When their statement is viewed in conjunction with the medical evidence demonstrating that the veteran's obesity results from his service-connected PTSD, and the evidence is construed in the manner most favorable to the veteran, the veteran's claim for service connection for sleep apnea, as secondary to PTSD is well-grounded and subject to further development on remand. The veteran also claims service connection for the residuals of a compression fracture to the back. Service medical records reflect that he sustained a shell fragment wound to the back. Current medical evidence reflects minimal degenerative joint disease of the lumbar spine. Thus the first two elements of a plausible service connection claim, injury in service and current medical diagnosis are presented. Also of record are VA medical reports dated in 1989 reflecting a diagnosis of old, slight compression fracture of the L1, and a 1995 VA examination report with the diagnosis of remote injury to the back with a report of a fracture having occurred in 1965, with some degenerative disease in the lumbar spine. When the 1995 statement is presumed credible for purposes of well-groundedness, and construed in the manner most favorable to the veteran, the final element of a plausible claim, a medical nexus is presented. Accordingly, the veteran's claim for service connection for residuals of a compression fracture of the back also is well-grounded. Entitlement to an Increased Evaluation for PTSD The veteran's claims for a higher evaluation for compensation benefits are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). Proscelle v. Derwinski, 2 Vet. App. 629 (1992). In general, disability evaluations are assigned by applying a schedule of ratings which represent, as far as can practicably be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155. Although the regulations require that, in evaluating a given disability, that disability be viewed in relation to its whole recorded history, 38 C.F.R. §§ 4.1, 4.2, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In Fenderson v. West, 12 Vet. App. 119 (1999) the Court found that the "present level" rule, set out in Francisco, is not applicable to original ratings. The significance of this distinction was that at the time of an initial rating, separate ratings could be assigned for separate periods of time based on the facts found-a practice known as "staged ratings." Fenderson, supra. Separate diagnostic codes identify the various disabilities. The Department of Veterans Affairs (DVA) has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). These regulations include, but are not limited to 38 C.F.R. § 4.1, and 4.2. Also, 38 C.F.R. § 4.10. 38 C.F.R. § 4.3 requires VA to resolve any reasonable doubt regarding the current level of the veteran's disability in his favor. In accordance with 38 C.F.R. § 4.7, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise the lower rating will be assigned. Inasmuch as the regulations pertaining to the rating of psychiatric disabilities were revised effective November 7, 1996, during the pendency of the veteran's appeal, he is entitled to evaluation of his disability under either the previously existing regulations or the newly amended regulations, - whichever is determined to be more favorable in his individual case. Karnas v. Derwinski, 1 Vet.App. 308, 313 (1991); VAOPGCPREC. 11-97. The regulations in effect at the time the veteran initiated his claim prior to November 7, 1996, provide that in evaluating psychoneurotic disorders, a significant degree of rating judgment is required. Impairment of social adaptability, in itself, the history and complaints provided by an appellant, or the categorization of the severity of impairment by a psychiatric examiner or treating physician is not determinative. Rather, significant factors for consideration are those abnormalities of conduct, judgment and emotional reactions that produce impairment of earning capacity. Time lost from work and decreased work efficiency are two of the most important determinants of disability. However, it must be shown that such industrial impairment is the result of the actual manifestations of the service- connected disorder. The objective findings and analysis of those findings, i.e., "actual symptomatology," are, therefore, afforded great emphasis in the evaluation of psychiatric disability. 38 C.F.R. §§ 4.126, 4.129 and 4.130. Under the general rating formula for psychoneurotic disorders, a 50 percent disability evaluation is for assignment where the ability to establish or maintain effective and wholesome relationships with people is considerably impaired and, by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. When the ability to establish and maintain effective or favorable relationships with people is severely impaired, and there are psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain and retain employment, a 70 percent evaluation is appropriate. A 100 percent evaluation requires that the attitudes of all contacts except the most intimate be so adversely affected as to result in virtual isolation in the community, and that there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities, such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior, or the demonstrable inability to obtain or maintain employment. 38 C.F.R. Part 4, Code 9411. In the case of Johnson v. Brown, 7 Vet. App. 95 (1994), the United States Court of Veteran's Appeals (Court) concluded that should the Board determine that any one of the three independent criteria listed in Diagnostic Code 9411 has been met, then a 100 percent rating should be assigned under the old criteria. The revised regulations, effective as of November 7, 1996, are cited, in pertinent part, below: When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the 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. (b) 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 solely on the basis of social impairment. General Rating Formula for Mental Disorders: 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, warrants a 100 percent rating. Where there is 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, a 70 percent rating is for assignment. 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, are the criteria for a 50 percent evaluation. In this case, the record reflects that on VA examination conducted in August 1989 the veteran was diagnosed with PTSD. At that time he related his history of service in Vietnam where he directly witnessed casualties and also sustained wounds himself. He reported that since returning from Vietnam he had noted interrupted sleep and recurrent nightmares of combat events, as well as waking flashbacks, which were both spontaneous and environmentally precipitated and occurred 3 to 4 times weekly. His complaints also included social withdrawal, irritability, difficulty with concentration, and stress intolerance, becoming agitated with minimal provocation. The veteran stated that he had a good employment record in spite of his symptoms. The report of the examiner's findings is partially legible. The veteran was noted to be tense in his affect and depressed. There were no thought or perceptual disorders, and memory and concentration were assessed as intact. Insight was considered poor and judgment was compromised under stress. The veteran testified before the hearing officer at the Newark RO in February 1991. At that time he related that since separation from service he had experienced insomnia which he attributed to PTSD. Reportedly he slept only two to three hours per night, with some relief from medication prescribed for his psychiatric disability. His treatment also included weekly psychotherapy sessions. He further noted recurrent nightmares related to the events in which he was wounded in service and to those occasions when he had witnessed others being injured. Waking flashbacks were again reported. The veteran complained of irritability and depression, admitting to suicidal thoughts on one occasion without plans. In response to questioning he indicated his work evaluations had been good; however he admitted that he had fallen behind in his certification program for his jog with the Disabled American Veterans, due to his difficulty with memory and retention. He acknowledged complaints of rigidity from his children, and suppressed hostility on his own part, as well as distrust of the government. He felt he had low self esteem and difficulty establishing relationships. The veteran asserted that his obesity was caused by PTSD, because the insomnia which he attributed to his psychiatric disability, caused him to overeat to make himself sleepy. He described his eating as compulsive and said that his psychiatrist had told him his obesity was related to his tension, anxiety and insomnia. The report of his April 1992 VA examination reflects that the veteran complained of severe mental distress and reported that his symptoms caused him to be socially withdrawn. He admitted a history of alcohol abuse. With regard to his employment with the Disabled American Veterans the veteran reported that he had lapses of concentration which prevented him from keeping up with his work. He said he had been told he might lose his job. He described severe sleep disturbances, including night sweats and combat nightmares. He reportedly slept only two hours a night. He also noted sleep apnea. In addition to impaired concentration the veteran complained of excessive fatigue. He reported intrusive memories and spontaneous waking flashbacks of combat. He suffered from persistent anxiety and depression and an exaggerated startle reaction to loud noises. Objective examination indicated the veteran was significantly depressed. Paranoid persecutory ideation was expressed, and there were ideas of reference. Memory and concentration were impaired. The veteran's insight was poor and his judgment was assessed as adequate for rating purposes. The diagnosis was chronic, severe, PTSD. When the veteran testified at his July 1993 hearing at the Newark RO, he admitted to occasional suicidal ideation. He noted his doctor had told him his excessive eating was an attempt to harm himself. Despite his testimony at an earlier hearing the veteran acknowledged that his work evaluations had not been good for some time. He said that his supervisor was assisting with the workload, and scrutinizing the veteran's work, due to his lapses of concentration and memory. The veteran said that his doctors had advised him to stop working. On VA psychiatric examination in September 1993 the veteran reported that he encountered difficulty and loss of efficiency on his job as a national service officer for the Disabled American Veterans due to impaired concentration, and memory problems. He also related that he had no friends and was estranged from family members. He was stress intolerant, frequently irritated, and easily agitated by minor provocation. As a result he isolated himself for fear of becoming violent. The veteran admitted to feeling paranoid and feared that he would die during his sleep. He related that he experienced frequent flashbacks, occurring 30 times a week, and reported he experienced a severe startle response to loud noises. The veteran also admitted using alcohol to stay calm after work. On objective examination the veteran was depressed. Psychomotor activity was reduced and his response time was prolonged. Speech production was sparse and nonspontaneous. Paranoid persecutory ideation was expressed. Although his memory was intact, his concentration was impaired. Insight was poor and his judgment was compromised under stress. The diagnoses were PTSD chronic, and depressive disorder, secondary to PTSD. VA outpatient treatment records dated in March 1993 to July 1994 reflect ongoing therapy and medication for PTSD to include symptoms of depression and anxiety with intrusive thoughts of stressful events in Vietnam. The latter were particularly problematic at the anniversary of dates when the veteran had sustained combat wounds, and were aggravated by his contact with other veterans who reported similar experiences. The veteran continued to complain of difficulty with memory and concentration, as well as work stress. A neuropsychological consultation conducted in June 1994 disclosed that his attention span was mildly foreshortened and concentration was average. With regard to memory the veteran's verbal learning for acquisition of five words was severely impaired. On other memory tests the veteran scored at least in the average range. The overall diagnostic impression was mild neuropsychological dysfunction considered likely to be secondary to the veteran's PTSD and depression. A progress note dated June 21, 1994, reflects the assertion of the treating psychologist that the veteran had decided to retire at the urging of his therapist and his treating psychiatrist. During the period reflected by the treatment records the veteran failed to control his weight, but the examiner noted that he maintained a neat appearance and purchased new clothing as needed to accommodate his increased size. In a statement signed in June 1994 the veteran's treating psychiatrist wrote that the veteran's service-connected PTSD and related physical problems had become severe, and the veteran was no longer able to work. Also of record is a copy of the veteran's resignation from his position with the Disabled American Veterans, effective June 24, 1994, in which he cited his physical problems, work related stress and his involvement with other veterans. When the veteran appeared for VA psychiatric examination in July 1994 he reported that his symptoms had worsened significantly. He said that severe depression had caused him to leave his job. He had reportedly been abusing alcohol and was unable to concentrate on his work. His work efficiency was poor. He could not tolerate the stress of the job and the pressure from his supervisor. He had become progressively isolated, both socially and from his family, and was currently residing at a mens' shelter. He had reportedly left home due to his fear that he would become violent. On objective examination the veteran appeared to be very fatigued. His affect was constricted and his mood depressed, at times tearful. Paranoid persecutory ideation was expressed. There were ideas of reference. His memory was intact, but concentration was impaired. The veteran had to be refocused several times during the interview. His insight was poor and judgment was compromised under stress. The diagnoses were PTSD, chronic, major depressive disorder with psychotic features, and alcohol abuse. Also of record are VA medical statements signed by the veteran's treating psychiatrist and his psychologist and dated in August 1994. His psychiatrist wrote that since 1989 the veteran had gained 140 pounds and was suffering from sleep apnea. Due to the latter condition the type of medication the veteran was able to use was restricted to those which were mild and did not significantly relieve his symptoms of depression and anxiety. He was self medicating with alcohol and also overeating huge amounts of food because he was depressed and unable to sleep. Treatment was ineffective. The veteran was unable to work at any job at the time of the statement and was considered to be unemployable in the future. His last job with Disabled American Veterans had produced increased depression and stress. The diagnoses were PTSD, major depression, sleep apnea, and obesity. The veteran's psychologist noted his treatment included individual psychotherapy and medication. He reported that the veteran had been advised to terminate his employment due to stress related to PTSD. His psychologist had also recommended that the veteran not seek new employment in the foreseeable future. In an additional statement dated in March 1995 the veteran's psychologist related that at the time the veteran left his position with the Disabled American Veterans not only had that job become too stressful for him, but it had become clear that the veteran was having a hard time maintaining the stable discipline necessary for employment, troubled as he was by the symptoms of PTSD, which included sleep disturbances, isolation, intrusive thoughts of combat trauma, and stress related to everyday travel and dealing with other people. He was isolated from family and friends and any kind of work was too stressful for the veteran for the immediate future. On neuropsychological reevaluation conducted in February 1995 the veteran's overall neuropsychological dysfunction had worsened to the level of moderate impairment. Also of record is a partial report of a VA psychiatric examination conducted in July 1995. According to the veteran's reports his disability had significantly worsened since his previous examination. He had not worked for approximately one year due to his psychiatric symptoms. He continued to isolate himself, socially and with regard to his family members. VA outpatient treatment records reflect ongoing treatment for PTSD through December 1996. When the veteran testified at his personal hearing at the Hartford RO in July 1997 he related that prior to leaving his job at the Disabled American Veterans, his work was affected by difficulty with concentration and memory which he attributed to PTSD. Reportedly his work reflected errors in spelling and writing. He stated that his psychiatrist had urged him to leave as early as 1993, but the veteran wanted to remain employed longer until his daughter finished school. The veteran's treating psychologist and psychiatrist have clearly opined that he has been unemployable due to severe and chronic PTSD since the time of his resignation of employment. There is no medical opinion of record to the contrary. Accordingly, the Board finds that the evidence supports the assignment of a 100 percent rating for PTSD, from that time, under the regulations in effect prior to November 7, 1996. Prior to his resignation of employment the record does not reflect the criteria for an increased rating under either the rating criteria previously in effect or the newly amended regulations. On application of the revised regulations to the pertinent evidence, it is clear that the record does not reflect the criteria for a 100 percent rating, which require 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. In fact there is no evidence of the symptoms of the severely cited. With regard to the criteria for a 70 percent rating, the record reflects that the veteran experienced difficulty in adapting to stressful circumstances such as his workplace. He also exhibited symptoms of significant depression during some of the pertinent period, which affected his ability for efficient and effective functioning. However, he is not shown to have had deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to the types of symptoms cited. His judgment was considered to be compromised under stress, but was also assessed as adequate for VA purposes. Although the veteran acknowledged occasional suicidal thinking, such thoughts were not shown to be a continuous or significant impediment to his industrial functioning during the relevant period. The veteran was noted to have sparse and nonspontaneous speech in September 1993, but there is no evidence that his speech was intermittently illogical, obscure, or irrelevant. He complained of irritability and easy agitation, but the problem described falls short of impaired impulse control, such as unprovoked irritability with periods of violence. In fact there is no evidence that the veteran ever acted in violence toward his family or in the workplace. Despite his out of control weight problem the veteran maintained his personal appearance and hygiene during the pertinent period. The difficulties he reported with personal relationships are not shown to amount to the inability to establish and maintain effective relationships. There is no evidence of spatial disorientation or obsessional rituals interfering with routine activities. Rather, the evidence reflecting the manifestations of PTSD during the pertinent period more nearly approximates the criteria for a 50 percent rating, under the amended regulations, which include occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; 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; and difficulty in establishing and maintaining effective work and social relationships. An increased rating is not warranted under the revised criteria. Similarly, under the regulations in effect prior to November 1996, the manifestations of the veteran's service-connected psychiatric disability most nearly reflect the criteria for a 50 percent rating which require psychoneurotic symptoms productive of reduced flexibility and efficiency levels resulting in considerable industrial impairment, warranting a 50 percent evaluation. In view of the veteran's continued full time employment, the record does not demonstrate that his service-connected disability was of such severity and persistence as to cause severe impairment of the ability to obtain and retain employment. Similarly, the criteria for a 100 percent rating were not demonstrated by the medical evidence of record. Not only was the veteran not demonstrably unemployable, but the evidence did not reflect virtual isolation in the community, or totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities, such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. Full consideration has been given to the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the veteran's disability in his favor. However, the medical evidence does not create a reasonable doubt regarding the level of this disability. The evidence does not reflect the presence of more severe symptomatology such as would warrant a higher evaluation during the period at issue. Accordingly, it is determined that the preponderance of the evidence is against assignment of an increased disability rating for the veteran's service-connected PTSD prior to his resignation of employment. Entitlement to a Total Rating Based on Individual Unemployability With regard to the veteran's claim of entitlement to a total rating based upon individual unemployability due to service- connected disability applicable regulations provide that a total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. In this case the veteran is not eligible for a total rating based upon individual unemployability from the time of his resignation of employment, because he is entitled to a 100 percent schedular rating for his service-connected PTSD. (38 C.F.R. § 4.16(a) (1999); Vettese v. Brown, 7 Vet.App. 31, 34-35 (1994) ("claim for total rating based upon individual unemployability due to service-connected disability presupposes that the rating for the condition is less than 100 [percent]"). This is a case in which the law is dispositive, and the appeal must therefore be denied. Sabonis v. Brown, 6 Vet.App. 426 (1994). However, it still must be considered whether the criteria for a finding of total disability based on individual unemployability due to service-connected disability were met prior to the effective date of the 100 percent rating for PTSD. ORDER Service connection is granted for obesity as proximal to PTSD. A 100 percent rating is granted for PTSD from the time of the veteran's resignation of employment. A rating greater than 50 percent for PTSD is denied prior to the time of the veteran's resignation of employment. The claims of entitlement to service connection for residuals of a compression fracture of the lumbar spine, and for sleep apnea as proximal to PTSD are well grounded. To this extent only, those appeals are granted. The claim for a total rating based upon individual unemployability due to service-connected disability as it applies to the period after the effective date of the assignment of a schedular 100 percent rating for PTSD, is denied as lacking in legal merit. REMAND The veteran has indicated his intention to appeal the denial of a rating greater than 30 percent for his service-connected skin disability, nummular eczema. In response to his notice of disagreement received in September 1995, that issue, along with other issues, was addressed by the RO in the supplemental statement of the case dated in March 1998. By letter dated in April 1998 the veteran was advised that no reply was necessary at that time if he felt he had made his position clear. It was also stated that his records would be forwarded to the Board, provided the veteran had filed a timely substantive appeal. In view of the possibly misleading statements set forth in that letter, it is determined that the veteran should not be prejudiced by any confusion which may have ensued. Thus he should be provided a further opportunity to perfect his appeal of the issue. Because the claims of entitlement to service connection for residuals of a compression fracture of the back and sleep apnea are well grounded, VA has a duty to assist the appellant in developing facts pertinent to those claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.159 (1999); Murphy v. Derwinski, 1 Vet. App. 78 (1990). The veteran's claims for increased rating of the residuals of shell fragment wounds affecting the left hip, left back, right arm, and right hip, thigh, and buttock, also are well grounded. In this regard the record reflects considerable medical treatment for symptoms referable to the back, both hips, and right upper extremity, with various assessments, to include myofascial pain syndrome, degenerative joint disease of the lumbar spine with radiculopathy, right trochanter bursitis, mild median nerve entrapment, and right ulnar neuropathy of unknown etiology. It is not clear to what extent the symptoms and findings reflected in the medical reports are related to the service-connected injuries. The situation is complicated by the fact that, although the veteran has undergone several related VA examinations during the pendency of these claims, all but one of the VA examiners noted that no medical record was available for review at the time of examination. In this regard it is noted that VA's obligation to assist the veteran in the development of evidence pertinent to his claim includes the conduct of a thorough and contemporaneous examination, which takes into account the records of prior medical treatment. See Green v. Derwinski, 1 Vet.App. 121, 124 (1991). In view of the foregoing, an additional VA examination is warranted to clarify the nature and extent of disability attributable to the residuals of shell fragment wounds. With regard to the evaluation of hemorrhoids the current medical evidence reflects Grade I internal hemorrhoids with no thrombosis. Inasmuch as the available findings do not sufficiently reflect the applicable rating criteria in order to allow a fully informed evaluation of the disability, an additional examination also will be required in this regard. cf. Massey v. Brown, 7 Vet. App. 204, 208 (1994). Accordingly, the case is REMANDED for the actions listed below. The law requires full compliance with all orders in this remand. Stegall v. West, 11 Vet.App. 268 (1998). Although the instructions in this remand should be carried out in a logical chronological sequence, no instruction may be given a lower order of priority in terms of the necessity of carrying out the instruction completely. 1. The RO and any physician to whom this case is assigned for an examination and/or a statement of medical opinion must read the entire remand, to include the explanatory paragraphs above the numbered instructions. 2. The RO should contact the veteran and advise him of the need to file a substantive appeal in order to perfect his appeal of the issue of increased rating for skin disability. The applicable period for submission should be provided. 3. The RO should also request that the veteran submit the names and addresses of all health care providers, VA or private, who have evaluated or treated him for sleep apnea, hemorrhoids, residuals of compression fracture of the back, and residuals of shell fragment wounds since July 1995. In addition he should be asked to provide identifying information to obtain records of the private medical treatment for his back which he received shortly after separation from service, as described at his February 1991 personal hearing. After securing the necessary releases, the RO should request copies of any previously unobtained medical records for association with the claims folder. 4. Following the completion of the above requested development, the veteran should be provided thorough VA neurological and orthopedic examinations to assess the nature and extent of the residuals of his shell fragment wound to the back, the left hip, the right hip, buttock and thigh, and the right upper extremity, as well as the etiology and extent of degenerative joint disease of the lumbar spine. The examiners must thoroughly review the claims folder prior to evaluating the veteran. All special tests and x-ray examinations deemed necessary should be conducted. The examination report(s) must clearly describe all clinical findings and diagnoses which are attributable to the residuals of the service-connected wounds, as distinguished from symptoms and findings attributed to any other cause. The following medical opinions should be provided based on the medical evidence of record. a. To the extent that joint pathology is under evaluation the examiner should be asked to determine whether the joint exhibits weakened movement, excess fatigability, or incoordination attributable to the service connected disability; and, if feasible, these determinations should be expressed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to any weakened movement, excess fatigability, or incoordination. b. Also in this regard, the examiner should be asked to express an opinion on whether pain could significantly limit functional ability during flare-ups or when each joint at issue is used repeatedly over a period of time. This determination should also, if feasible, be portrayed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups. c. The orthopedic examiner should provide an opinion, as to whether it is at least as likely as not that the veteran has a lumbar spine disability manifested by slight compression fracture and degenerative joint disease, which is attributable to the service- connected shell fragment wound of the back. All opinions expressed must be supported by reference to the medical evidence. 5. The veteran should also be provided an appropriate VA medical examination to assess the etiology of his sleep apnea, to clarify the relationship, if any, between that condition and his service- connected PTSD and obesity. All indicated special studies and tests should be completed. The examiner must review the claims folder prior to evaluating the veteran, and should determine, on the basis of available medical evidence whether the veteran's sleep apnea has been caused or aggravated by his service-connected disabilities. If the examiner finds that an increase in the severity of sleep apnea is attributable to service-connected disabilities she/he should provide a medical opinion as to what level of increased disability is attributable to that aggravation. All opinions expressed must be supported by reference to the medical evidence of record. 6. Finally the veteran should be provided a VA examination to determine the nature and extent of hemorrhoids present. The examination findings must reflect the evaluation criteria, i.e., it should be noted whether or not there are large or thrombotic, hemorrhoids which are irreducible, with excessive redundant tissue, evidencing frequent recurrences, and whether there is evidence of persistent bleeding with secondary anemia, or fissures. 7. Prior to reviewing the veteran's claims the RO should examine the claims folder to ensure that all development has been accomplished as directed by this remand. 8. Following the completion of the above requested development the RO should review the veteran's claim for service connection for sleep apnea, as secondary to PTSD, in accordance with the provisions of 38 C.F.R. § 3.310(a) (1999), and the directives set forth by the Court in Allen regarding aggravation, as well as his claims for service connection for residuals of compression fracture of the lumbar spine, increased ratings for hemorrhoids and the residuals of shell fragment wounds, and if appropriate increased rating for a skin disability. Each claim must be considered on the basis of all evidence of record and all applicable law and regulations. The issue of total rating based upon individual unemployability must also be readjudicated with regard to the period prior to the effective date of the 100 percent schedular rating for PTSD. If any action taken remains adverse to the veteran, he and his representative should be provided a supplemental statement of the case and the applicable time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The appellant need take no action until otherwise notified. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. G. H. SHUFELT Member, Board of Veterans' Appeals - 1 -