Citation Nr: 1328609 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 10-06 206 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to June 23, 2011, and a rating in excess of 70 percent thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from September 1999 to May 2001 and from August 2004 to January 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which continued a 50 percent rating for PTSD. The matter has otherwise been adjudicated by the RO in Nashville, Tennessee. In a January 2013 rating decision, the RO assigned a 70 percent rating for PTSD effective from June 23, 2011. The Veteran had previously requested a Board hearing as part of his appeal. However, in correspondence dated May 2013, the Veteran indicated that he wished to withdraw that request, and therefore the appeal will proceed. See 38 C.F.R § 20.702(e) (2012). A portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDING OF FACT Throughout the period on appeal, the Veteran's PTSD has been manifested by multiple inpatient admissions, ongoing suicidal ideation with plan, marked limitations in social and occupational functioning, and GAF scores ranging primarily from 35 to 45. CONCLUSION OF LAW The criteria for a 100 percent rating for PTSD have been met during the appeal period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) outlines procedural assistance VA must provide to claimants in certain cases. If the VCAA is applicable, the Board must ensure that the required notice and assistance provisions of the law have been properly applied. In this case, the Board is granting in full the benefit sought on appeal. Assuming that any error was committed with respect to the duty to notify or the duty to assist, such error was harmless and will not be further discussed. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The Veteran is assigned a 50 percent rating under Diagnostic Code 9411 prior to June 23, 2011, and a 70 percent rating thereafter. A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the Veteran's own occupation or name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100, reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores ranging from 51 to 60 reflect moderate symptoms. DSM-IV at 46-47. Scores ranging from 41 to 50 reflect serious symptoms. Id. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication, or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. Id. The evidence in this case reflects other diagnosed psychiatric disorders in addition to PTSD. However, the evidence does not differentiate symptoms attributable to these conditions versus those due to PTSD. Therefore, all potentially service-connected symptoms have been attributed to the Veteran's service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998)(the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition). The Veteran did not specifically file a claim for an increased rating. Rather, the RO undertook a special review of his assigned rating following a period of inpatient treatment in September 2008. This treatment effectively serves as the Veteran's "claim" for the purpose of establishing the period on appeal. The Veteran was admitted for inpatient care in September 2008 for 4 days. His complaints included suicidal ideation, and he reported that he was not able to cut his wrists because his wife saw him get the knife and stopped him. He reported some audio hallucinations of Arabic chanting. His GAF score was 35. During an October 2008 follow-up visit, the Veteran appeared disheveled and slightly anxious. His mood and affect were blunted. Memory and judgment were intact. A November 2008 depression screening revealed findings consistent with moderately severe depression. In December 2008, the Veteran was admitted for inpatient treatment for a period of 5 days for complaints of suicidal ideation. He also verbalized thinking that he might get a hammer and hit his wife, but did not carry this out. He admitted to using cocaine and marijuana. On examination, the Veteran's mood was labile and his affect was constricted. The examining physician noted active suicidal and homicidal ideation. He received inpatient care and was discharged after 5 days. VA records dated January 2009, March 2009, and May 2009 show the Veteran reported depressed mood, poor sleep, and combat-related nightmares. The Veteran also reported that his stress and his medications prevented him from being able to work. In June 2009, the Veteran underwent a vocational analysis from the Tennessee Department of Rehabilitation Services. The following abilities were noted to be markedly limited: perform activities with a schedule, maintain regular attendance and punctuality, work in coordination or proximity with others without distraction, complete a normal workday and workweek without interruptions from symptoms, and respond appropriately to changes in the work setting. The Veteran was moderately limited in several other areas of functioning. The report concluded that the Veteran was unable to meet the mental demands of unskilled labor. The Veteran underwent a VA examination in December 2009. He reported having homicidal thoughts when he got angry with someone. He denied any current suicidal ideation, but reported thoughts of wanting to harm himself about once a week, and has thought about cutting his wrists. On examination, the Veteran reported daily thoughts that criminals were out to harm him, and the examiner noted these to be persistent paranoid delusions. He reported auditory hallucinations in the form of Arabic chanting, and said he saw spirits of people he had never seen before, and the examiner noted these to be persistent hallucinations. His GAF score was 45, and the examiner noted a GAF score of 35 to 45 for the past year. The Veteran was admitted for inpatient treatment for 4 days in April 2010 due to complaints of suicidal ideation with plan, depression, and associated cocaine abuse. On admission, his GAF score was 40. He was treated and released. The Veteran was readmitted for inpatient care in for 9 days in June 2010. He had presented for a rehabilitation intake interview, but was admitted after expressing depression and suicidal thoughts, saying he wanted to cut his wrists with a steak knife. He was not sleeping well and had ongoing nightmares related to Iraq. He admitted to cocaine use on a fairly regular basis. He was treated and released after demonstrating compliance with his medication regime. Records dated July 2010 and October 2010 show the Veteran stated he was doing "OK." His GAF score was 50. In December 2010, his GAF score was 55. During June 2011 VA examination, the Veteran reported panic attacks, depression, passive suicidal ideation, and obsessive behavior that did not interfere with activities. His GAF score was 38. The Veteran was admitted for inpatient treatment twice in August 2011 for a total period of 11 days. His GAF score was noted to be as low as 35 during this period. He was admitted again in October 2011 for 7 days. From December 2011 through February 2012, he was admitted for a total of approximately 50 days. In May 2013, he was admitted for 15 days. His GAF score was again noted to be 35. All inpatient admissions related to complaints of depression and suicidal ideation. A 100 percent rating is warranted in this case. During the period on appeal, the Veteran's PTSD has been manifested by repeated inpatient treatment for symptoms of suicidal ideation, often with plan. These admissions noted GAF scores of 35 to 40, which is indicative of major impairment in areas such as work, family relations, and mood. Additional findings from the December 2009 and June 2011 VA examiners corroborate these findings. The June 2009 vocational assessment concluded that the Veteran was not capable of meeting the mental demands of unskilled labor. Collectively, these findings demonstrate that the Veteran's PTSD approximates the total occupational and social impairment contemplated by the 100 percent rating under Diagnostic Code 9411. ORDER A 100 percent rating for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs