Citation Nr: 0810729 Decision Date: 04/01/08 Archive Date: 04/14/08 DOCKET NO. 02-08 812 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for coronary artery disease. 2. Entitlement to an initial rating higher than 30 percent for post-traumatic stress disorder. 3. Entitlement to a rating higher than 10 percent for hypertension. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Harrigan, Associate Counsel INTRODUCTION The veteran, who is the appellant, served on active duty from September 1966 to July 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in December 2001 of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana, which granted service connection for post-traumatic stress disorder and coronary artery disease and assigned initial 30 percent disability ratings for each, and denied an increased disability rating for service- connected hypertension, evaluated as 10 percent disabling. In February 2003, the veteran appeared at a hearing before the undersigned Veterans Law Judge. The Board remanded the case in June 2003 for further evidentiary development. In July 2005, the veteran appeared at a second hearing on the same claims before an Acting Veterans Law Judge, who has since left the Board. In November 2005, the Board again remanded the case for further development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). In August 2007, the Board afforded the veteran the opportunity for another hearing and he was instructed to respond within 30 days if he wanted a new hearing and that, if he did not respond within the 30 days, the Board would proceed with the appeal. As the veteran has not responded, the Board will proceed with the appeal. The undersigned Veterans Law Judge, who conducted the hearing in February 2003 hearing will decide the case. The transcripts of the hearings are of record. FINDINGS OF FACT 1. Since the effective date of the award, coronary artery disease has not resulted in more than one episode of acute congestive heart failure in the past year, or a workload of greater than 3 METs, but not greater than 5 METs with dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent 2. Since the effective date of the award, under the General Rating Formula for Mental Disorders, post-traumatic stress disorder is productive of a disability picture that equates to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior or self- care and normal conversation without evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as or the equivalent to such symptoms as or symptoms associated with the diagnosis of post-traumatic stress disorder under DSM-IV such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; disturbances of motivation; and difficulty in establishing and maintaining effective work and social relationships. 3. Hypertension is not manifested by diastolic pressure predominantly 110 or more; or systolic pressure predominantly 200 or more. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 30 percent for coronary artery disease have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2007); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2007). 2. The criteria for an initial rating higher than 30 percent for post-traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2007); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). 3. The criteria for a rating higher than 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2007); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a), VA must notify the claimant of the information and evidence not of record that is necessary to substantiate the claims, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. Under 38 C.F.R. § 3.159, VA must request that the claimant provide any evidence in the claimant's possession that pertains to the claims. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Also, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the VA must provide at least general notice of that requirement to the claimant. Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post- adjudication VCAA notice by letters, dated in February 2003, in November 2005, and in June 2006. The notice included the type of evidence needed to substantiate the underlying claims of service connection for coronary artery disease and post-traumatic stress disorder, namely, evidence of an injury or disease or event, causing an injury or disease, during service; evidence of current disability; and evidence of a relationship between the current disability and the injury or disease or event, causing an injury or disease, during service. The notice included the type of evidence needed to substantiate the claim for increase for hypertension, namely, evidence that the disabilities had become worse and the effect that worsening has on the claimant's employment and daily life. The veteran was informed that VA would obtain service medical records, VA records, and records from other Federal agencies, and that he could submit private medical records or authorize VA to obtain the records on his behalf. He was asked to submit evidence that would include evidence in his possession that pertained to the claims. The notice included the provisions for rating the disabilities and for the effective date of the claims. With regard to the initial claims for increase for coronary artery disease and post-traumatic stress disorder, the RO provided the veteran with content-complying VCAA notice on the underlying claims of service connection. Where, as here, service connection has been granted and initial disability ratings have been assigned, the claims of service connection have been more than substantiated, they have proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once the claims of service connection have been substantiated, the filing of a notice of disagreement with the rating of the disability by the RO does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, further VCAA notice under 38 U.S.C.A. § 5103(a) and § 3.159(b)(1) is no longer applicable in the claims for initial higher ratings for coronary artery disease and post-traumatic stress disorder. Dingess at 19 Vet. App. 473. As for the claim for increase for hypertension, the content of the VCAA notice substantially complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112 (2004) (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473 (2006)(notice of the elements of the claim); and of Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008) (evidence demonstrating a worsening or increase in severity of a disability and the effect that worsening has on employment and daily life, except general notice of the criteria of the Diagnostic Code under which the claimant is rated, which consists of a specific measurement or test result). To the extent that the VCAA notice came after the initial adjudications, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The timing error was cured by content- complying VCAA notice after which the claims were readjudicated as evidenced by the supplemental statement of the case, dated in February 2007. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.) To the extent that the VCAA notice did not include the Diagnostic Code under which hypertension is rated, at this stage of the appeal, when the veteran already has notice of the pertinent Diagnostic Code and rating criteria as provided in the statement of the case, there is no reasonable possibility that further notice of the exact same information would aid in substantiating the claim. As the content error did not affect the essential fairness of the adjudication of the claim for increase for hypertension, the presumption of prejudicial error as to the content error in the VCAA notice is rebutted. Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (compliance with the VCAA is not required if no reasonable possibility exists that any notice or assistance would aid the appellant in substantiating the claim); Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claims. The veteran appeared at hearings in February 2003, before the undersigned Veterans Law Judge, and in July 2005. The RO has obtained the veteran's service medical records as well as relevant VA records. The veteran himself has submitted numerous private records. The veteran has not identified any additional records for the RO to obtain on his behalf. Further, VA has conducted necessary medical inquiry in an effort to substantiate the claims. 38 U.S.C.A. § 5103A(d). The veteran was afforded VA examinations in October and December 2006 to evaluate coronary artery disease, post- traumatic stress disorder, and hypertension. There is no evidence in the record dated subsequent to the VA examinations that shows a material change in the disability to warrant a reexamination. 38 C.F.R. § 3.327(a). As there is no indication of the existence of additional evidence to substantiate the current claims, the Board concludes that the duty-to-assist provisions of the VCAA have been complied with. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2007). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007). Coronary Artery Disease Coronary artery disease is currently rated 30 percent under Diagnostic Code 7005. Under Diagnostic Code 7005, the criteria for the next higher rating, 60 percent, are more than one episode of acute congestive heart failure in the past year; or a workload of greater than 3 METs, but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Private medical records disclose that in February and September 1999 echocardiograms revealed mild left ventricular hypertrophy with an ejection fraction of 55 percent. In April 2001, an echocardiogram revealed left ventricular hypertrophy with an ejection fraction of 50 to 55 percent. The veteran's symptoms included chest pressure, radiating to the right arm with pain, and tachycardia with palpitations. On VA examination in October 2001, the veteran complained of occasional palpitations, chest pain, and dizziness. He denied shortness of breath and a history of congestive heart failure. An echocardiogram revealed mild left atrial enlargement and an ejection fraction of 55 percent. In February 2003, the veteran testified that he had occasional chest pains, shortness of breath, and dizziness. Private medical records disclose that in April 2003 on stress testing METS were 12.7. In a statement, dated in April 2003, a private physician reported that the veteran was seen for chest pain in March 2003 and at the time the veteran's blood pressure was elevated and he had run out of medication. The physician stated that in September 2002 an echocardiogram revealed an ejection fraction of 50 to 55 percent. On VA examination in August 2003, the veteran complained shortness of breath after walking less than one block. He denied syncope, near syncope, exertional chest pain, or dizziness. It was noted that in July 2003 an echocardiogram revealed an ejection fraction of 55 percent. The impression was normal ventricular systolic function with an ejection fraction of 55 percent in a clinical METS level of 7-10 and no evidence of acute or chronic heart failure. On VA examination in February 2004, the veteran complained of chest pain with palpitations. History included congestive heart failure seven years previously. The impression was history of angina and of congestive heart failure. In July 2005, the veteran testified that he was being treated for coronary artery disease by a private physician. Private medical records disclose that in April 2004 an echocardiogram revealed an ejection fraction of 50 to 55 percent. In July 2005, an echocardiogram revealed an ejection fraction of 55 percent. On stress testing METS were 10.40. On VA examination in October 2006, an echocardiogram revealed an ejection fraction of 55 percent. Analysis The criteria for the next higher rating, 60 percent, are more than one episode of acute congestive heart failure in the past year; or a workload of greater than 3 METs, but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The evidence, consisting of both VA and private medical records, contain no documentation of congestive heart failure during the appeal period beginning in 2001. There was a history of congestive heart failure, dating to the 1990s, but no evidence of acute or chronic heart failure during the appeal period. As for workload measured by METS, the documented METS during the appeal period were 12.7, 7 to 10, and 10.40, which do not more nearly approximate or equate to 3 METs, but not greater than 5 METS. Although the veteran has complained of shortness of breath, fatigue, angina, and dizziness, the symptoms are clearly not the result of a workload measured by 3 METs, but not greater than 5 METS, as the METS are well over 5 METS as documented. As for left ventricular dysfunction, repeated echocardiograms from 1999 to 2006 reveal ejection fractions of 50 to 55 percent, which do not more nearly approximate or equate to an ejection fraction of 30 to 50 percent. For these reasons, the preponderance of the evidence is against an initial rating higher than 30 percent for coronary artery disease at any time during the appeal period, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Post-Traumatic Stress Disorder Post-traumatic stress disorder is currently rated 30 percent disabling under 38 C.F.R. § 4.130, the General Rating Formula for Mental Disorders, Diagnostic Code 9411. Under Diagnostic Code 9411, the criteria for a 30 percent rating are occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Under Diagnostic Code 9411, the criteria for the next higher rating, 50 percent, are 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 per week, difficulty in understanding complex commands; impairment of short- or 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. The Global Assessment of Functioning is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score in the range of 41 to 50 represents serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score in the range of 51 to 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score in the range of 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. On VA examination in September 2001, for social history, the examiner noted that the veteran was married in 1973 and the marriage lasted only a year and that he married a second time in 1975 and he was still married. The examiner also noted that the veteran had five children and one child still lived with the veteran and his wife. The veteran complained of a strained relationship with his wife, for example, on occasion they would not speak to one another for days. He also complained of a strained relationship with his adult children because of his problem controlling his anger. The veteran stated that he was involved in church, but he had no other social involvement outside of his immediate family. For employment history, the examiner noted that the veteran worked as a pipe fitter and that he was currently employed with the same company since 1986. The veteran denied disciplinary problems on the job, but he had problems getting along with co-workers. He stated that the job required that he work in pairs and often others refused to work with him because of his attitude. The veteran complained of problems with interpersonal relationships, irritability, sleep disturbance, and family and social isolation. The examiner noted that the veteran was not on psychiatric medication or in psychological therapy. The examiner described the veteran: as casually dressed and appropriately groomed; his affect was restricted throughout the interview and his mood was dysphoric; his speech rate, tone and volume were within normal limits; and his judgment was completely intact. Speech content suggested clear and logical flow of thoughts and ideas. The veteran denied symptoms indicative of auditory or visual hallucinations and there was no evidence of delusional thinking. The veteran denied any specific suicidal or homicidal intent, but stated that in the past he had acknowledged passive thoughts of death. The veteran stated that he had intrusive thoughts of combat and of Vietnam. He stated that he had flashbacks occurring about two times per month and he became upset when he was reminded of his experiences such as when he saw war movies. The veteran stated that he attempted to avoid people or things that remind him of Vietnam and he had great difficulty feeling love for others. He felt different from other people and reported that he lived on a day to day basis. The veteran also complained of insomnia, irritability, anger outbursts, extreme hypervigilance, and poor concentration. The veteran also complained of feeling sad, of a significant loss of interest in activities that were previously pleasurable, and of feeling worthlessness. The examiner commented that the veteran was able to maintain employment despite symptoms of post-traumatic stress disorder and that post-traumatic stress disorder mostly impacted his social functioning in personal relationships with his family and in his ability to maintain relationships outside of his immediate family. The examiner assigned a Global Assessment of Functioning (GAF) score of 65. In a letter, dated in January 2003, two VA mental health-care providers at a VA post-traumatic stress disorder clinic stated that the veteran had participated in weekly treatment sessions for his post-traumatic stress disorder since May 2002. They reported that the medical records showed that the veteran's post-traumatic stress disorder was having a negative impact on his ability to function at work and socially and that chronic interpersonal difficulties and high levels of anger/irritability seemed to interfere significantly with his ability to interact with others at work and on a social level. It was noted that according to the veteran the only reason he had not lost his job was because of his experience and number of years on the job. The two mental health-care providers stated that the impact of post-traumatic stress disorder and secondary depression on his social, vocational, and psychiatric functioning was severe. In February 2003, the veteran testified that he was in weekly group therapy and that he was to start individual therapy. He described problems at work getting along with co-workers and some supervisors and at home with his wife. In January 2004, the veteran testified that he was in individual therapy and on medication for post-traumatic stress disorder. He again described problems at work getting along with co-workers and some supervisors and at home with his wife and adult child. On VA examination in March 2004, the examiner noted that the veteran remained married to his second wife of 26 years, but the marriage was strained because of his anger and irritability and poor communication. The veteran stated that he had a strained relationship with his adult children, whom he sees when they visit. He complained of social isolation at work and that he has lost interest in activities he once enjoyed. The examiner noted that the veteran was not in therapy and he has stopped taking his medication because of the side effects. The examiner reported that the veteran remained employed, that he had not lost time from work, and he was able to maintain steady employment and had not experienced a significant decline in his work performance, but he did have episodes when he had difficulty controlling his anger. The examiner described the veteran as alert and oriented. He was neatly groomed with adequate hygiene. His affect remained stable thought the interview, showing little emotion and maintaining no eye contact. His speech was generally normal with regard to production, volume, content, and clarity. No delusions or hallucinations were detected during the interview. The veteran denied suicidal ideation. While he occasionally pondered what it would be like if he were not around for both he and his wife, he denied he would ever follow through on the idea. The veteran complained of recurrent and distressing dreams, but he denied intrusive thoughts or flashbacks. The veteran avoided thoughts, feelings, and conversations associated with Vietnam. He had lost interest in activities he previously enjoyed, and he had a sense of detachment or estrangement from others. He had a foreshortened sense of the future. The veteran complained of sleep disturbance, irritability that interfered with his relationships, exaggerated startle response, hypervigilance, and difficulty concentrating. He also had feelings of helplessness and hopelessness and sadness and guilt associates with his Vietnam experiences. The examiner commented that although the veteran reported a general decline in functioning, that is, in his relationship with his wife, he was able to maintain steady employment without major incident and his symptomatology had remained stable over time. The examiner assigned a GAF score of 55, reflecting moderate difficulty in social functioning. In July 2005, the veteran testified about problems at work getting along with co-workers and at home with his wife. On VA examination in November 2006, the examiner noted that the veteran remained married to his second wife of 30 years and that he was employed full time for the last twenty years. The veteran described himself as a loner. He described his marriage relationship as poor and his relationship with his adult children as fair. The examiner reported that the veteran's behavior during the examination was appropriate. The veteran was alert and oriented. He had no memory loss or impairment. He had a flat affect and appeared depressed. His speech was generally normal. He did not have any delusions or hallucinations. He denied current suicidal ideation, but not homicidal ideation for which he had no plan. He did not have any impairment of thought process or communication. He was able to maintain personal hygiene and activities of daily living. As for symptoms of post-traumatic stress disorder symptoms, the veteran avoided war movies, and he felt detachment from others. He also had symptoms of hopelessness, low self esteem, low energy, and feelings of worthlessness and guilt. The examiner commented that the veteran was able to maintain steady employment for 20 years and that the veteran's symptoms mostly impacted his social relationships and quality of life. The examiner assigned a GAF score of 50. In an addendum in December 2006 and after a review of the veteran's file, the examiner reported no changes to the November 2006 report and that there was no significant change in the symptoms since the examination in 2004. Analysis Reconciling the various reports into a consistent disability picture, two elements of the present disability emerge. First, the veteran has symptomatology that is associated with the rating criteria under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, and symptomatology not covered in the rating criteria, as well as symptoms associated with the diagnosis of post-traumatic stress disorder under the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV), which is referred to in 38 C.F.R. Part 4, § 4.130 (rating mental disorders). All of the veteran's symptoms are considered in the analysis. And two, from 2001 to 2006, the veteran's symptomatology has been consistent without significant change even though the GAF scores range from 50 to 65. Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather that the presence of symptoms, pertaining to the criteria for the next higher rating, 50 percent rating, that is, 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 per week, difficulty in understanding complex commands; impairment of short- or 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. As for the effect of the veteran's symptoms on occupational and social impairment with reduced reliability and productivity, the veteran has worked for 20 years as a pipe fitter without disciplinary action or significant time lost from work, and he has remained married for over 30 years, although there is evidence of marital discord. And although the veteran sees himself as a loner and he has had difficulties with his co-workers and he is isolated at work and at home, he still is reliable on the job and his productivity at work has not been a problem. Also, under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, such symptoms as: abnormal speech, panic attacks more than once per week, difficulty in understanding complex commands, impairment of short- or long- term memory, impaired judgment, impaired abstract thinking, and disturbances of motivation have not been shown. While the veteran has a flatten effect, a depressed mood, and difficulty in maintaining effective work and social relationships under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, and symptoms of hopelessness, low self esteem, and low energy, as well as symptoms associated with the diagnosis of post-traumatic stress disorder in DSM-IV, but not listed in Diagnostic Code 9411, such as sleep disturbance, nightmares, irritability, anger, intrusive thoughts, startle response, flashbacks, avoidance of activities, and emotional detachment, the symptomatology has not resulted in occupational and social impairment with reduced reliability and productivity as previously stated as the veteran has been able to maintain steady, full time employment for 20 years without a adverse job action or significant time lost and in married relationship for 30 years albeit with difficulty in maintaining an effective relationship. Nevertheless, the symptoms do not rise to the level of occupational and social impairment with reduced reliability and productivity required for a 50 percent rating. Although the GAF scores range from 50 to 65 and a GAF score in the range from 41 to 50 suggests serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job, the record shows that the veteran is able to keep a job and has done so for 20 years. A GAF score in the range of 51 to 60 represents moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers or co-workers), which best describes the veteran's disability and which is encompassed in the current rating of 30 percent, generally functioning satisfactorily with routine behavior and self-care. For the above reasons on the basis of VA examinations in 2001, 2004, and 2006, including GAF scores in the range from 50 to 65, the Board finds that the effect of the symptomatology does not equate to or more nearly approximate the criteria of a 50 percent rating, that is, occupational and social impairment with reduced reliability and productivity under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, and symptomatology not covered in the rating criteria, as well as symptoms associated with the diagnosis of post-traumatic stress disorder under DSM-IV. As the preponderance of the evidence is against an initial rating higher than 30 percent for post-traumatic stress disorder at any time during the appeal period, the benefit- of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Hypertension Hypertension is currently rated 10 percent under Diagnostic Code 7101. Under Diagnostic Code 7101, the criteria for the next higher rating, 20 percent, are diastolic pressure predominantly 110 or more; or systolic pressure predominantly 200 or more. Private medical records disclose that in September 2001, blood pressure was 152/98. On VA examination in October 2001, the veteran's blood pressure was 170/100 sitting, 152/84 supine, and 166/90 standing. Private medical records from March 2003 reveal blood pressure ratings of 166/108 and 232/110 during an exercise stress test. On VA examination in August 2003, blood pressure was 140/80. On VA examination in February 2004, the blood pressure readings were 140/80, 142/85, and 136/74. Private medical records from October 1004 show a blood pressure reading of 134/88. In May 2005, blood pressure was 166/40. In July 2005, eight diastolic blood pressure readings were predominantly 80 or less, the systolic blood pressure reading were 162 or less. On VA examination in October 2006, the blood pressure readings were 140/66, 126/70, 140/78, 130/80, and 130/84. Analysis The criteria for the next higher rating, 20 percent, are diastolic pressure predominantly 110 or more; or systolic pressure predominantly 200 or more. The evidence, consisting of both VA and private medical records, covering the period from 2001 to 2006 document diastolic pressure predominantly below 110, or systolic pressure predominantly below 200. For these reasons, the preponderance of the evidence is against a rating higher than 10 percent for hypertension at any time during the appeal period, and the benefit-of-the- doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER An initial rating higher than 30 percent for coronary artery disease is denied. An initial rating higher than 30 percent for post-traumatic stress disorder is denied. A rating higher than 10 percent for hypertension is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs