Citation Nr: 0812679 Decision Date: 04/16/08 Archive Date: 05/01/08 DOCKET NO. 04-21 317 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an increased rating for post-traumatic stress disorder, (PTSD), currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Clayte Binion, Attorney ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The veteran served on active duty from March 1968 to March 1970. This case is currently before the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. When this issue was before the Board in May 2006, it was remanded for additional development of the record. As the requested development has been accomplished, the case is again before the Board for appellate consideration. The Board notes that the decision in this case to grant a 100 percent schedular evaluation for PTSD represents a complete grant of the benefit sought on appeal, and renders moot the issue of entitlement to a total rating based on individual unemployability due to service-connected disabilities. Accordingly, this decision is limited to the issue set forth on the preceding page. FINDING OF FACT The occupational and social impairment from the veteran's PTSD more nearly approximates total than deficiencies in most areas. CONCLUSION OF LAW The criteria for a 100 percent evaluation for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDING AND CONCLUSION As explained below, the Board has found the evidence currently of record to be sufficient to establish the veteran's entitlement to the complete benefit sought on appeal. Therefore, no further development is required under 38 U.S.C.A. §§ 5103, 5103A (West 2002) or 38 C.F.R. § 3.159 (2007). Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2006). 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 (2007). A 30 percent rating is warranted for 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted for PTSD if there 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 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted for 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent evaluation is warranted for 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. 38 C.F.R. § 4.130, Diagnostic Codes 9411. 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. 38 C.F.R. § 4.7. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2007) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the veteran's PTSD. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. In this regard the Board notes that where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The veteran was admitted to a VA hospital in August 2004 and reported that he was experiencing problems with sleep disturbance, nightmares, and anxiety attacks. He reported that he felt on edge all the time and that he worried about everything. He related that he was depressed and had infrequent suicidal thoughts. He denied audio and visual hallucinations, but said he felt paranoid all the time. On mental status evaluation, the veteran's affect was slightly constricted and his mood was euthymic. His insight and judgment were good. The diagnosis on discharge was PTSD. The Global Assessment of Functioning score was 48. On VA psychiatric examination in April 2005, the veteran complained of nightmares, sweating, being unhappy, and that he had little interest in anything. On mental status evaluation, he had little spontaneous speech. His answers to questions were logical, relevant and coherent. There was no loose thought association, tangentiality or circumstantiality. There were no paranoid or grandiose delusions. The veteran admitted to getting into fights three to four months earlier. He reported panic attacks which he said occurred when he was in crowds. He asserted that during the attacks, he felt jittery and nervous. The veteran's mood was depressed and his affect was mood congruent. He endorsed problems staying asleep at night. He was oriented to person and place, but said he did not know the day. The diagnoses were PTSD, and major depressive disorder, severe. The Global Assessment of Functioning score was 50. VA outpatient treatment records dated from 2004 to 2007 have been associated with the claims folder. It was noted in March 2005 that the veteran felt distant and cut off from others, including his spouse. He said he was emotionally numb and that he could never relax. He described problems with irritability and anger on a daily basis. The examiner characterized most of the veteran's symptoms as being severe. She commented that the veteran's PTSD symptoms had caused functional impairment in all spheres of his life, and that they were severe. The diagnoses were PTSD, chronic, severe; major depressive disorder; and panic disorder. The Global Assessment of Functioning score was 40/42. It was noted in January 2006 that he was being followed for severe PTSD and depression. It was reported that he had been having a bad period of extreme hyperarousal and irritability. He was feeling edgy and depressed. It was noted that he had recently killed his dog because it was barking. The veteran stated that he told his wife that the dog had died due to an accident, but he said that he was disturbed by what he had done. It was noted that the most recent Global Assessment of Functioning score was 44 in October 2005. An update of the March 2005 report summarized above was done in August 2006. It was noted that the veteran's PTSD had caused him problems at work (prior to his retirement), and that if he had not had a supervisor who overlooked his anger outbursts, he would have lost his job due to PTSD. It was further indicated that the veteran's problems with PTSD had affected his concentration and led to depression. His PTSD was again described as severe. The examiner commented that due to the problems detailed in the report, the veteran was not employable, as even minor stress exacerbated his PTSD symptoms. It was also concluded that the veteran's life was very constricted due to his severe PTSD and related depressive symptoms. The diagnoses were PTSD, chronic, severe; major depressive disorder; and panic disorder, with agoraphobia. The Global Assessment of Functioning score was 40/41. The examiner stated that the veteran's Global Assessment of Functioning scores had remained consistently in the low 40's since he had been treated at the VA mental health clinic. In addition, the examiner observed that the veteran had a flattened affect and difficulty connecting with feelings of warmth or other tender feelings. The veteran had evidence of social impairment, and the examiner pointed out that the veteran had socialized prior to service, but was now a loner and had a very distant relationship with his wife. The Board acknowledges that following a VA psychiatric examination in January 2007, the examiner conceded that the veteran had PTSD, but commented that it was no worse than his current rating. He pointed out that the veteran was relaxed during the interview and stated that it was his opinion that the veteran's main problems stemmed from his personal choices. The veteran's only specific reference to trauma from Vietnam was the fact that he experienced nightmares three to four times a week. The examiner also noted that psychological testing suggested the possibility that the veteran might have exaggerated his symptoms during the interview. The diagnoses were PTSD, mood and impulse disorder, not otherwise specified, personality disorder, not otherwise specified with narcissistic and antisocial features. The Global Assessment of Functioning score associated with both PTSD and the mood disorder was 60. In April 2007, the examiner reviewed the claims folder, including the January and August 2006 reports described above, and confirmed his opinion expressed at the time of the January 2007 VA psychiatric examination. In August 2007, the veteran was again afforded a VA psychiatric examination. The examiner noted that the veteran was highly withdrawn and quiet, and his affect was very flat. The veteran was well-oriented and coherent. His responses were clear, relevant and goal-directed. He reported a seriously depressed mood and endorsed severe symptoms of PTSD, as well as major depressive disorder. The examiner observed that the veteran had an extensive and long-term treatment record with mental health professionals at VA. He pointed out that the record indicated consistent agreement in the assigned diagnoses and Global Assessment of Functioning score among multiple mental health professionals. The record demonstrated a clear pattern of consistent Global Assessment of Functioning scores in the low 40's. The examiner added that the veteran's medical record showed that he had been compliant with his treatment regimen and had regularly attended outpatient mental health treatment. He opined that the mental health professionals who had been treating the veteran over an extended time were able to form a more complex understanding of the veteran. Therefore, as rated by the Global Assessment of Functioning scale, the veteran's overall level of functioning was more likely than not most accurately assessed as in the low 40's. The diagnoses were PTSD, chronic, severe; and major depressive disorder, recurrent, severe without psychotic features. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning score is based on 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 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 31-40 is indicated when there is, "Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood." Id. A score of 41-50 is assigned where there are, "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 51-60 is appropriate where there are, "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)." Id. Almost all of the Global Assessment of Functioning scores assigned during the period pertinent to this claim have been indicative of serious impairment and an inability to maintain employment. In addition, the record reflects that the veteran has been unemployed throughout the period of the claim and that he is socially isolated with the exception of a distant relationship with his wife. In the Board's opinion, the VA outpatient treatment records, the VA psychiatric examination of April 2005, and the opinion of the VA examiner in August 2007, provide a reasonable basis for concluding that the social and occupational impairment from the veteran's PTSD more nearly approximates total than deficiencies in most areas. Accordingly, the veteran is entitled to a 100 percent rating for PTSD. ORDER Entitlement to a 100 percent rating for PTSD is granted, subject to the governing law and regulations pertaining to the payment of monetary benefits. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs