Citation Nr: 0120962 Decision Date: 08/16/01 Archive Date: 08/17/01 DOCKET NO. 01-01 433A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Scott T. Pethybridge, Associate Counsel INTRODUCTION The veteran had active service from January 1964 until January 1967. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a March 2000 decision of the Department of Veterans' Affairs (VA) Regional Office in St. Louis, Missouri (RO), which denied the benefit sought on appeal. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this claim has been obtained. 2. The veteran's PTSD is productive of total occupational and social impairment. CONCLUSION OF LAW The criteria for a disability rating of 100 percent for PTSD have been met. 38 U.S.C.A. § 1155 (West 1991); Veteran's Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000); 38 C.F.R. §§ 4.1-14, 4.125-4.130, Diagnostic Code 9411 (2000). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran claims entitlement to a disability evaluation in excess of 50 percent for his service-connected PTSD. Essentially, the veteran contends that the severity of his symptomatology warrants a higher evaluation. At the outset, the Board finds that all relevant facts have been properly and sufficiently developed and that no further assistance to the veteran is required in order to comply with the duty to assist as mandated by the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, § 3(a), 114 Stat. 2096 (2000). In this regard, the Board notes that the veteran has been afforded a VA examination in connection with his claim and that his VA medical records have been obtained. Upon receiving a Notice of Disagreement (NOD) from the veteran regarding his increase in rating to 50 percent, a Statement of the Case was issued to the veteran explaining the reason for the rating and setting forth the symptomatology necessary for an increase in rating beyond 50 percent. Also, the veteran's representative has filed a written brief on appeal on the veteran's behalf. As such, the Board finds that the VA's duty to assist has been fulfilled and that this claim is ready for appellate review. Disability ratings are determined by evaluating the extent to which a veteran's service connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (2000). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. Nevertheless, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). A review of the record reveals that the veteran was initially granted service connection for PTSD in April of 1999 and granted a 30 percent disability rating. In December of 1999, the veteran sought re-evaluation of his claim. A resulting March 2000 rating decision increased the veteran's disability evaluation from 30 to 50 percent, and the evidence of record upon which the ratings decision was based is discussed below. The veteran filed an NOD with respect to his increased rating, thus initiating this appeal. Of record is a listing of the veteran's treatment history. These listings reveal that the veteran has been receiving psychiatric treatment at VA since early 1995. Also of record are the veteran's VA outpatient treatment records from November 1998 until September 1999. A January 1999 record briefly discusses the veteran's difficulties sleeping, and indicates that his quality and length of sleep have improved with medication, though his wife reported that his sleep seemed more restless than it had been. The veteran was diagnosed with: Axis I - PTSD; chronic; Major depression, recurrent, secondary to PTSD. Axis II - No diagnosis. Axis III - S/P pituitary adenomectomy, May 1998; "Post polio syndrome," DJD; GERD/HH; hyperlipidemia. Axis IV - 3- moderate-anniversary of suicide of son-in-law's father. Axis V - [GAF ] 65 in the last 12 months; 63 now. An April 1999 record shows the veteran complaining of worsened depression, nightmares, sleep, short-term memory, as well as lack of energy and awakening in a cold sweat. An accompanying record of the same date assigned the veteran with a GAF of 63, with Axis I through V diagnoses identical to those in January 1999, and reported above. June 1999 treatment records show the veteran experiencing continued difficulty with PTSD symptoms including re-experiencing his experiences in Viet Nam and avoiding people. In an August 1999 treatment record, the veteran complained of his irritability, stating, "sometimes I blow up over nothing." He also reported nightmares two to four times per week and intrusive thoughts about Viet Nam. An August 1999 treatment record shows calm and euthymic. He credited his improved temper control and improved sleep to medications he had been prescribed. The veteran was diagnosed as Axis I - PTSD, chronic; Major depression, recurrent; secondary to PTSD. Axis II - No diagnosis. Axis III - Allergic to testosterone patch; S/P pituitary adenomectomy-May, 1998. Axis IV - None obvious. Axis V - 65 in the last 12 months, 65 now. The veteran underwent a February 2000 VA examination regarding his PTSD. At the examination, the veteran complained of depression, nervousness, nightmares, lack of energy, excessive anger and irritation, low self-esteem, concentration problems, feelings of guilt, and an inability to relax. The veteran reported that he was "depressed 80-95 percent of the time" and will "isolate myself from everybody because that is the only way I can deal with it." The veteran reported being "nervous around large groups of people" and must avoid going to church and shopping at large stores. The veteran related that there was an occasion at a store where he almost hit someone who accidentally touched him. Whenever he goes into stores he feels like "something is going to happen." He is always anticipating "having problems." The veteran reports having nightmares approximately two or three times per week, and generally wakes up fighting. The veteran said that he becomes angry "when something doesn't go right." This happens even when little things go wrong. He stated he has an "instant reaction" and will do such things as throw a hammer through the wall. He said he regrets it later, but too late to stop it. The veteran presented as casually dressed and demonstrating appropriate grooming and hygiene, other than being unshaven. His speech was clear and the veteran had a good ability to express himself. His affect was sad and overall mood seemed depressed. Orientation was appropriate, and thinking was spontaneous, logical, and productive. Thought content was notable for preoccupation with his physical problems and resulting sense of worthlessness. The veteran's relationships with others seemed fair but with a low frequency of contact. His self-esteem was impaired. There were no substance abuse problems. Memory and concentration were slightly impaired, and reasoning skills indicated that the veteran's thinking was primarily concrete, with an estimated intellectual functioning level in the low average range. The veteran's judgment seemed diminished by his depression and anger. The examiner concluded by stating the veteran, "is now having problems on a daily basis, to a moderate to severe degree. He demonstrates impaired social relationships, judgment, mood, activity level, and ability to complete daily living tasks such as shopping." The veteran was diagnosed with: Axis I - PTSD, delayed onset. Axis II - No diagnosis. Axis III - back pain. Axis IV - Unemployed. Axis V - 41. Also of record are treatment records from February to September 2000. February 2000 treatment notes indicate that the veteran was attending group therapy sessions addressing management of PTSD symptoms. A March 2000 treatment record reports the veteran as euthymic, calm, and neatly groomed. This record reports the veteran relating details regarding anxiety attacks he recently experienced. The veteran stated one occurred "when just sitting in the living room with my parents." He stated he had another anxiety attack the same day while in a crowded restaurant. The veteran related, "It felt like the walls were closing in." The veteran felt that his heart was "racing like; I just knew I had to leave the room [both times]." The veteran denied any other physical symptoms, as well as the recent or proximate ingestion of drugs. The clinician indicated that it was not clear if this was an emerging panic disorder, or simply an isolated incident. The veteran was diagnosed with: Axis I - PTSD, chronic, 30 percent SC, Major Depression; recurrent, secondary to PTSD. Axis II - No diagnosis. Axis III - Allergic to testosterone patch; S/P pituitary adenomectomy, May 1998. Axis IV - 3-moderate-recent anxiety symptoms. Axis V - 65 in the last 12 months, 60 now. An April 2000 treatment record reports the veteran continuing to attend group therapy sessions for management of PTSD. A September 2000 treatment record shows the veteran looked calm, euthymic, and neatly groomed. The record also shows that the veteran started attending church and informed his Sunday school teacher that he didn't like to be crowded by people, so not to be alarmed if he ever got up and walked out during class. However, the treatment record indicates that the veteran's anxiety attacks had been largely controlled with medication. This record indicates that the veteran was doing well, but this was the case only due to careful exposure management and medication. He was diagnosed with: Axis I - PTSD, chronic, 30 percent SC; Major depression, recurrent, secondary to PTSD. Axis II - No diagnosis. Axis III - Allergic to testosterone patch; S/P pituitary adenomectomy, May 1998' "Post polio syndrome," DJD; GERD/HH; hyperlipidemia. Axis IV - 2-mild-church crowd exposure. Axis V - 60 in the last 12 months; 60 now. An August 2000 record written by a VA clinical psychologist summarizes the veteran's treatment history and symptomatology. The record indicates that the veteran had met the criteria for diagnosis of chronic delayed onset PTSD and recurrent major depression. The veteran's GAF was reported as 42. The veteran had received treatment at 39 individual psychotherapy sessions, 17 psychopharmacologic sessions, and 60 group sessions related to PTSD. The record reports that the veteran has good motivation and attempts to reduce distressing symptoms related to PTSD in order to improve his quality of life. However, the veteran's PTSD symptoms "have proven to be highly intractable," including, re-experiencing events via nightmares, intrusive memories, anger dyscontrol, difficulty with trust and problems with interpersonal relationships, hypervigilence, and intimacy. The veteran was judged unemployable. The record also indicates that the severity of his PTSD symptoms has compromised his adaptability to other life symptoms, such as his pituitary adenomectomy, post polio syndrome, and degenerative joint disease. The RO evaluated the veteran's PTSD as being 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent disability evaluation is assigned for 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 100 percent disability rating is assigned where there exists 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 or 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. Relating the veteran's symptomatology to the applicable rating criteria, the Board finds that a 100 percent disability rating is appropriate. The veteran has made statements concerning actions taken or nearly taken that the Board finds demonstrate grossly inappropriate behavior that makes the veteran a persistent danger to himself and others. In this regard, the veteran related in his VA examination that "sometimes I blow up over nothing." The veteran said that he becomes angry "when something doesn't go right." This happens even when little things go wrong. He stated he has an "instant reaction" and will do such things as throw a hammer through the wall. He said he regrets his actions later, but does so too late to stop it. The veteran has also admitted to nearly hitting a man in a store for inadvertently touching him. The veteran also reports that he frequently awakens from nightmares fighting. Addressing another applicable criterion, the veteran has demonstrated an inability to perform activities of daily living. He has stated he is unable to attend church or shop at large stores because of the large groups of people he encounters there. He has stated that he feels nervous whenever he is in places where groups of people are present. The veteran also reports an occasion where he had to leave a room because he felt "the walls closing in on [him]." Due to the veteran's severe depression associated with his PTSD, he also frequently isolates himself from others. Regarding this symptomatology, the veteran stated he is "depressed 80- 95 percent of the time" and will "isolate [him]self from everybody because that is the only way [he] can deal with it." The Board also notes that the veteran has, in the past, received several GAF scores in the sixties. However, two out of three of the veteran's most recent GAF scores are in the low forties. As it is the veteran's the present level of disability that is of primary concern, the Board accords the veteran's most recent GAF scores the greatest weight. Also, the Board finds that GAF scores in the low forties are most consistent with the severity of symptomatology the veteran has evidenced. The Board also notes that in the veteran's August 2000 VA treatment records, the treating psychologist termed the veteran's PTSD symptoms "highly intractable" and stated that the veteran was "unemployable." Summarizing the veteran's symptomatology, the VA examiner wrote that the veteran "is now having problems on a daily basis, to a moderate to severe degree. He demonstrates impaired social relationships, judgment, mood, activity level, and ability to complete daily living tasks such as shopping." Accordingly, a disability evaluation of 100 percent for PTSD is granted. In reaching this decision, the Board has considered the complete history of the veteran's PTSD, as well as the current clinical manifestations of this disability and its effect on the veteran's earning capacity. See 38 C.F.R. §§ 4.1, 4.2, 4.41. All other pertinent aspects of 38 C.F.R. Parts 3 and 4 have also been considered. Inasmuch as the above decision results in an award of the maximum benefit available, consideration of the provisions providing for assignment of an extra-schedular evaluation is unnecessary. See 38 C.F.R. §§ 3.321(b)(1); 4.125- 4.130. ORDER Subject to the rules and regulations governing awards of monetary benefits, a 100 percent rating for post-traumatic stress disorder is hereby granted. Bruce Kannee Member, Board of Veterans' Appeals