Citation Nr: 1333617	
Decision Date: 10/24/13    Archive Date: 10/24/13

DOCKET NO.  13-22 677	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Louisville, Kentucky


THE ISSUE

Whether a reduction in the evaluation for posttraumatic stress disorder (PTSD), from 100 to 0 percent, was proper.


REPRESENTATION

Veteran represented by:	Disabled American Veterans


WITNESSES AT HEARING ON APPEAL

The Veteran and his VA licensed clinical social worker


ATTORNEY FOR THE BOARD

David A. Brenningmeyer, Counsel

INTRODUCTION

The Veteran served on active duty from April 1988 to October 1993, to include service in the Southwest Asia theater of operations during the Persian Gulf War.

This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky which, in pertinent part, implemented an October 2012 proposal to reduce the Veteran's rating for PTSD from 100 to 0 percent.  The reduction was made effective July 1, 2013.

In a May 2013 notice of disagreement, the Veteran requested a hearing before a Decision Review Officer at the RO.  In August 2013, he withdrew that request.  He asked, instead, that he be scheduled for a Board hearing before a Veterans Law Judge sitting at the RO.

In September 2013, the Veteran and his VA licensed clinical social worker testified at a Board hearing before the undersigned Veterans Law Judge sitting at the RO.  A transcript of that hearing has been prepared and associated with the claims file.

During the hearing, the Veteran submitted additional evidence in support of his appeal, together with a waiver of initial review of that evidence by the agency of original jurisdiction (AOJ).  See 38 C.F.R. § 20.1304(c) (2013).  He also waived initial AOJ review of any additional VA treatment records that were thereafter procured.  Therefore, the Board may properly consider such evidence.

The Board notes that, in addition to the paper claims file, there are electronic (Virtual VA and Veterans Benefits Management System (VBMS)) files associated with the Veteran's claim.  The documents in the electronic files include a transcript of the Veteran's September 2013 Board hearing and additional VA medical records, which the Board has reviewed.  The remainder of the documents in the electronic files are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal.

This appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002) and 38 C.F.R. § 20.900(c) (2013).


FINDINGS OF FACT

1.  In a February 2009 rating decision, the RO increased the Veteran's rating for PTSD from 50 to 100 percent, effective October 8, 2008, based on a finding that the condition was causative of total occupational and social impairment.

2.  In a May 2010 rating decision, the RO continued the 100 percent rating.

3.  The evidence pertaining to whether the Veteran currently has PTSD is, at least, in relative equipoise.

4.  The competent and credible evidence fails to establish that the Veteran's PTSD has improved.


CONCLUSION OF LAW

Resolving reasonable doubt in the Veteran's favor, the reduction in the evaluation for PTSD, from 100 to 0 percent, was not proper.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.105, 4.3, 4.130, Diagnostic Code 9411 (2013).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

In a February 2008 rating decision, the RO in Columbia, South Carolina, granted the Veteran's claim of entitlement to service connection for PTSD.  The RO allowed the claim based, in part, on evidence corroborating the Veteran's assertions to the effect that his unit had engaged in combat in Southwest Asia during the Persian Gulf War, and the report of a December 2007 VA examination reflecting a diagnosis of PTSD.  The RO evaluated the condition as 50 percent disabling, effective March 15, 2007.

In a February 2009 rating decision, the RO in Louisville, Kentucky, increased the Veteran's rating for PTSD from 50 to 100 percent, effective October 8, 2008.  In a May 2010 rating decision, the RO continued the 100 percent rating.

In October 2012, following review examinations in June 2012 and August 2012, the RO entered a rating action proposing to reduce the Veteran's evaluation for PTSD from 100 to 0 percent.  As noted previously, the RO thereafter implemented the proposed reduction in an April 2013 rating decision, effective July 1, 2013.

On appeal, the Veteran contends that his evaluation should not have been reduced.  During the September 2013 Board hearing, he and his representative advanced argument to the effect that the reduction was premised upon the results of testing that were improperly interpreted as demonstrating malingering.  They argued that, due to his level of education and other factors, the Veteran did not understand portions of the tests; nevertheless, he was asked to do his best to complete them.  They further maintained that the Veteran's condition had not improved since 2010; rather, if anything, it had gotten worse.  They asserted, in essence, that, in light of other evidence record reflecting diagnoses of PTSD and associated psychiatric conditions, it was improper for the RO to have reduced his rating.

As set forth below, the Board is restoring the Veteran's 100 percent rating for PTSD, effective July 1, 2013.  As the Board is granting the full benefit sought on appeal, there is no need to engage in any analysis with respect to whether the requirements of the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013)), or the due process provisions of 38 C.F.R. § 3.105(e), have been satisfied.

Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability.  38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013).  Separate diagnostic codes identify the evaluations to be assigned to the various disabilities.

If 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 (2013).

PTSD is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013).  A zero percent rating is warranted if the condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.  The highest available rating, 100 percent, is warranted if the disorder is manifested by 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 oneself or others; an intermittent inability to perform the activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, one's own occupation, or one's own name.  Id.; see also Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (indicating that the Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on the claimant's social and work situation).

One factor which may be considered in evaluating PTSD is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness."  Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); see also Richard v. Brown, 9 Vet. App. 266 (1996).

GAF scores ranging from 61 to 70 indicate that the patient has 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 is generally functioning pretty well, and has some meaningful interpersonal relationships.  Scores between 51 and 60 are indicative of 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 peer or coworkers).

GAF scores between 41 and 50 indicate 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).  Scores between 31 and 40 are indicative of 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 (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).  See DSM-IV.

Congress has provided that a Veteran's disability rating will not be reduced unless an improvement in the disability is shown to have occurred.  38 U.S.C.A. § 1155 (West 2002).  For reductions in rating to be properly accomplished, specific requirements must be met.  See 38 C.F.R. § 3.344 (2013); see also Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992).

Under 38 C.F.R. § 3.344, if a rating has been in effect for five years or more, there must be material improvement in the disability before there is any rating reduction.  In such cases, the provisions of 38 C.F.R. § 3.344(a) and (b) are for application.  Because the 100 percent rating here at issue was in effect for less than five years, the provisions of 38 C.F.R. § 3.344(a) and (b) are not applicable.

The United States Court of Appeals for Veterans Claims (Court) has noted, however, that 38 C.F.R. §§ 4.2 and 4.10 apply generally to all rating reductions and that "in any rating-reduction case not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work."  See Brown v. Brown, 5 Vet. App. 413, 420-22 (1993); see also 38 C.F.R. § 4.1, 4.2, 4.13 (2013); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991).

In considering the propriety of a reduction, the Board must focus on the evidence of record available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition has demonstrated actual improvement.  Cf. Dofflemyer, 2 Vet. App. at 281-82.  Care must be taken, however, to ensure that a change in an examiner's evaluation reflects an actual change in the Veteran's condition, and not merely a difference in the thoroughness of the examination or in descriptive terms, when viewed in relation to the prior disability history.

When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant.  38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2013).

Here, the record shows that the 100 percent rating assigned for PTSD in February 2009 was based on the report of a December 2008 VA examination.  Following an approximate two-hour interview with the Veteran, and review of the evidence in his claims file, the examiner (a VA staff psychologist) concluded, in pertinent part, that the Veteran had PTSD, major depressive disorder, and psychotic disorder NOS (not otherwise specified); that the major depressive disorder and psychotic disorder NOS were secondary to PTSD and combat trauma; that the Veteran had a GAF score of 35; and that he suffered total incapacity in occupational functioning, and was unemployable, due to symptoms of PTSD.  In arriving at those conclusions, the examiner noted that the Veteran was found to be an able and reliable historian, and that his self-report was judged to be credible, reliable, and a valid source of information.

In May 2010, the 100 percent rating was continued based on the report of March 2010 VA review examination.  Following an interview with the Veteran, and review of the evidence in his claims file, the examiner (a second VA psychologist) concluded, in pertinent part, that the Veteran had PTSD and depressive disorder NOS; that the depressive disorder was secondary to PTSD; that the Veteran had a GAF score of 40; and that he suffered total occupational and social impairment, and was unemployable, due to PTSD and associated depressive symptoms.

The basis for the reduction in the Veteran's rating was the reports of June 2012 and August 2012 VA review examinations.

After reviewing the claims file, the June 2012 examiner (a third VA psychologist) concluded, in essence, that the Veteran did not have PTSD, or any other psychiatric disorder; that he was malingering; and that his GAF score was not able to be accurately assessed.  In support of his conclusions, the examiner noted that the Veteran reported progression of PTSD symptoms; that a progressive course of PTSD is an atypical presentation; that the Veteran complained of extreme symptoms; that he complained of a large number of severely impairing symptoms; that there was a lack of acute disturbance during the interview; and that MMPI-2 (Minnesota Multiphasic Personality Inventory-2) testing revealed clear psychometric evidence of gross over-reporting.

The August 2012 examiner (a fourth VA psychologist) likewise concluded that the Veteran was malingering.  The examiner observed that the atypical presentation in the Veteran's case was not supportive of PTSD; that he did not appear to engage in persistent avoidance of stimuli associated with his in-service trauma, as would be required for the diagnosis; that he denied psychiatric problems in the past (in 1995); that mental health treatment was first obtained in 2007; that evidence of functioning was not supportive of the reported level of dysfunction; and that it was not possible to estimate a current GAF score due to inconsistent and distorted symptom reporting.  The examiner indicated that he had consulted with two other psychologists on the case, and they concurred with his conclusions.  The examiner clarified that his conclusion did not preclude the presence of a mental disorder.  Rather, it reflected that an accurate diagnosis could not be made due to distortion of symptom report and presentation, as well as evidence of bias in a medico-legal context.

At the time of the proposed reduction, the claims file also contained other, contradictory, evidence, in the form of reports from a supervisory VA social worker, J.M., and two private psychologists, E. Johnson, Ph.D., and A. Adkins, Ph.D.

In a May 2012 report, pertaining to a 60-minute individual psychotherapy visit, the supervisory VA social worker, who first treated the Veteran in 2008, reiterated his prior diagnostic conclusion that the Veteran had chronic and severe PTSD, r/o (rule out) associated psychotic features.  The social worker recorded a GAF score of 42 and stated, "It is felt that the [the] Veteran is currently unemployable and that the current condition has worsened.  Prognosis is very poor."

Dr. Johnson examined the Veteran in connection with a claim for disability benefits from the Social Security Administration (SSA).  The examination required two sessions, in May 2012 and June 2012, as the Veteran had to return to complete the MMPI-2-RF (MMPI-2-Restructured Form) as a result of difficulties with vision and concentration.  In the final analysis, it was noted that the test results were invalid.  Dr. Johnson observed that previous testing suggested that the Veteran had average intellectual ability (intelligence quotient of 91); that he had a reading grade level of 5.1; the he had impaired delayed recall on mental status examination; that he was distracted by symptoms; and that his concentration varied and was often poor. 

Based on his interview with the Veteran, observation, review of VA mental health records, and information provided by the Veteran's wife, Dr. Johnson concluded that the Veteran had chronic and severe PTSD with psychotic features and depressive disorder NOS, with a GAF score in the range of 38 to 40.  As to the Veteran's occupational and social impairment, Dr. Johnson stated:

[The Veteran] cannot make occupational[] adjustments, and in fact he has difficulty with daily tasks and relationships.  He is socially unpredictable and emotionally unstable.  He cannot maintain "concentration, persistence, or pace" in a work setting.  He is hypervigilant and suspicious of others.  Reliability is expected to be poor.  [The Veteran] can understand and carry out simple instructions part of the time, but he wouldn't be able to sustain these abilities on a consistent basis due to distractions from pain and psychological stresses.

On an associated SSA form, Dr. Johnson checked boxes indicating that the Veteran was moderately impaired in terms of understanding, remembering, and carrying out simple instructions; that he was markedly impaired in his ability to make judgments on simple work-related decisions; and that he was extremely impaired in terms of understanding, remembering, and carrying out complex instructions, and making judgments on complex work-related decisions.  

Dr. Adkins examined the Veteran in September 2012, also in connection with a claim for SSA disability benefits.  After examining the Veteran, and conducting testing with respect to verbal comprehension, perceptual reasoning, working memory and processing speed (the Wechsler Adult Intelligence Scale, 4th Edition, or WAIS-IV), Dr. Adkins observed, in pertinent part, that the Veteran's ability to perform and comprehend verbally was in the low average range (16th percentile), that his ability to perceive and manipulate non-verbally within his environment was in the average range (25th percentile), that his ability to retain and manipulate information was in the low average range (18th percentile), that his ability to quickly and accurately process information and perform tasks was in the average range (30th percentile), and that his overall intellectual abilities were in the borderline range, with a full scale IQ score of 85 (16th percentile).

In the final analysis, Dr. Adkins concluded that the Veteran had no to mild impairment regarding his ability to understand, retain, and follow instructions, and to perform simple, repetitive tasks, but that he had marked to severe impairment regarding his ability to relate to others (including fellow workers and supervisors), to adapt to the workplace, and to tolerate the stress and pressures associated with day-to-day work activity.  The diagnostic assessment was that he had major depressive disorder, generalized anxiety disorder, PTSD, and pain disorder.  A GAF score of 41 was recorded.

After the reduction in the Veteran's evaluation was effectuated, the Veteran underwent another examination by Dr. Johnson, in April 2013, in an effort to assist the Veteran in clarifying his prior diagnosis of PTSD.  Dr. Johnson administered testing (the Personality Assessment Inventory, or PAI).  He specifically advised the Veteran that the MMPI-2-RF administered during the previous examination was invalid, and suggested over-reporting; encouraged him to answer the test questions in an honest and frank manner; and advised him to encircle the numbers of any items he did not understand so that the examiner could attempt to define words or otherwise clarify the content of the statement.  It was noted that the Veteran circled a significant number of items during the course of the assessment, but that he had interpreted most of them correctly and mostly wanted to explain his response.

Dr. Johnson indicated that the Veteran had a high elevation (T=77) on the NIM scale of the PAI, which suggested the possibility of over-reporting.  However, he noted that persons with severe psychopathology might score high on various scales, that the results were nevertheless to be interpreted cautiously, and that other validity scales were in the normal range.  In the final analysis, Dr. Johnson concluded that the Veteran's profile was consistent with his past diagnoses and reported problems.  The final diagnostic assessment was that the Veteran had severe, chronic PTSD; depressive disorder, r/o major depressive episode; and r/o pain disorder, with psychological and medical factors.  The GAF score was 48.  Dr. Johnson stated, "I would consider him to be unable to work full- or part-time for more than a year."

Thereafter, the RO obtained another VA examination in July 2013.  Relative to the two prior diagnoses of malingering, the examiner noted that research had shown that the MMPI-2 generally requires between a 5th and 9th grade reading skill for valid administration, and that exaggerated MMPI-2 profiles can be a function, at least in part, of poor reading skills.  On testing at the time of examination, the Veteran was found to function in the overall borderline range of intellectual ability with commensurate achievement levels in reading, attaining well below his educational level (12th grade) on word reading (5th grade) and sentence comprehension (10th grade).  Based on that information, the examiner concluded that the current MMPI-2 data showing symptom over-reporting was due, in part, to poor reading apprehension.  The examiner noted that this did not negate other noted factors, such as the Veteran's tendency to exaggerate reported symptoms and functional impairment, but that it did impose limitations on what could be inferred in terms of diagnosis.

Based on the results of the examination, and review of the claims file, it was the examiner's conclusion that the Veteran did not meet the diagnostic criteria for PTSD.  The examiner questioned the Veteran's assertions to the effect that he avoided being around Arabic people, inasmuch as the 2010 U.S. Census did not reflect that there were Arabic people in the county where the Veteran resides.  The examiner also questioned why, if the Veteran awoke on repeated occasions choking his wife, his wife would continue to sleep with him more often than not, as reported.  The examiner further appeared to doubt the Veteran's assertions with respect to avoiding conversation about combat, inasmuch as it did not appear from the records that he had trouble discussing traumatic events and stressors with his VA therapist, and had volunteered a great deal of information about his war time experiences, unsolicited and without difficulty, to past VA and private examiners.

On the other hand, the examiner concluded that there was sufficient evidence that the Veteran was reporting, at least at some level, bona fide anxiety and depressive symptoms.  However, the examiner concluded in an addendum to the initial report that it was unlikely that the Veteran's anxiety and depressive symptoms were related to service.  In support of that conclusion, the examiner noted, in part, that the Veteran had not sought medical treatment for more than 25 years after the in-service stressors occurred, and that research on delayed onset traumatic stress conditions indicate that only a small percentage of Veterans are estimated to actually have delayed onset PTSD or subthreshold PTSD/PTSS (posttraumatic stress syndrome) symptoms.  The final diagnostic assessment that the Veteran had anxiety disorder NOS, depressive disorder NOS, and borderline intellectual functioning.  It was noted that the symptoms of each diagnosis overlapped, that the level of impairment attributable to each diagnosis could not be distinguished, and that he had a GAF score of 65.

Records from SSA were also received.  The records reflect, among other things, that, on examination in August 2005, the Veteran complained of problems with stress and depression "over the last several years," and reported having flashbacks related to events in the military.  The diagnostic assessment was that he had dysthymic disorder, r/o PTSD.  The records also reflect that he was treated for dry eye syndrome.  His claim for SSA disability was initially denied in April 2008, in part, because the adjudicator found that his psychiatric complaints seemed "somewhat exaggerated . . . ."

On SSA examination in June 2008, it was noted that the Veteran was possibly subthreshold for PTSD.  In October 2008, the Veteran was diagnosed with PTSD with "moderate" difficulties in maintaining social functioning and "moderate" difficulties in maintaining concentration, persistence, or pace.  On SSA consultative examination in October 2009, results of WAIS-IV testing revealed a full scale IQ of 63.  It was noted that the results of testing were considered to be an underestimate of his ability.  However, he was administered a test for malingering and achieved a score that was interpreted as generally indicative of reasonable effort.  It was noted that he did not report enough symptoms during the assessment to meet the diagnostic criteria for PTSD.  The final diagnostic assessment was that he had borderline intellectual functioning, with a GAF score of 61.  Also included in the records from SSA was a July 2009 report from Dr. Johnson containing diagnoses of PTSD, psychotic disorder NOS, associated with PTSD, and depressive disorder NOS, with a GAF score of 35.

In December 2012, the Veteran was granted SSA disability benefits, effective May 25, 2005, based on impairment attributable to back pain and psychiatric disability (diagnosed as major depressive disorder, generalized anxiety disorder, PTSD, and pain disorder).

VA treatment records, dated through August 2013, continue to reflect diagnostic assessments of PTSD, together with diagnoses of r/o associated psychotic features, depressive disorder NOS, depression, alcohol abuse, alcohol dependence in early remission, and alcohol dependence in full sustained remission, with one examiner (a psychiatrist) diagnosing probable substance-induced psychotic disorder (SIPD) and another examiner (a psychologist) diagnosing personality disorder NOS.  The clinical records from May 2010 forward contain GAF scores in the range of 39 to 57, in no particular temporal pattern.

It is repeatedly noted in the records from the Veteran's treating VA therapist (a supervisory social worker, as noted above), including in May 2013, that the Veteran is unemployable as a result of PTSD, and that his prognosis is very poor.  In terms of the apparent discord with respect to diagnosis, the therapist explained, in June, July, and August 2013 clinical records, that the Veteran was not a good candidate for psychological testing for several reasons, including his intellectual functioning, level of education, and difficulty in understanding many words.  The therapist noted that prior psychological evaluations by VA clinical psychologists had resulted in diagnoses of PTSD, and that other clinical psychologists in the community had also diagnosed PTSD, including one who conducted testing.  The therapist assigned a GAF score of 42.

During the September 2013 Board hearing, the Veteran's treating VA therapist-who identified himself as a licensed clinical social worker and former Chief of Mental Health-testified that he had been treating the Veteran since 2008.  The therapist pointed out that the Veteran had been diagnosed with PTSD by three separate VA compensation examiners (in December 2007, December 2008, and March 2010) prior to the findings of malingering in 2012.  The therapist offered his opinion that he, too, believed the Veteran satisfied the diagnostic criteria for PTSD.  He testified that the VA examiner who diagnosed malingering in June 2012 was stopped from doing compensation examinations "awhile back," and was "released" and is no longer working for VA.  The therapist observed that the Veteran was shown to have borderline intellectual functioning, not a borderline personality, and, in effect, that his level of intellectual functioning called into question the results of psychological testing that were relied upon to render the diagnosis of malingering.  The therapist also observed that the Acting Chief of Psychiatric Care at the VA Medical Center in Huntington, West Virginia had very recently (in August 2013) confirmed a diagnosis of PTSD.  As to the Veteran's level of disability, the therapist opined that the Veteran's condition had not materially improved; rather, it had actually gotten worse.

At the hearing, the Veteran submitted lay statements in support of his claim from his wife, daughters, and two life-long friends.  The statements are to the effect that the Veteran was a joy to be around as a child; that he was depressed and angry when he returned from Iraq; that he screams "about things he sees but no one else can"; that he continues to struggle with symptoms associated with service; that he is nervous, angry, and easily agitated; that he wants to take a gun with him wherever he goes "because you never know when you might need it"; and that the situation has put a lot of stress on his family.

Based on review of the entire record, the Board finds that the evidence supports the conclusion that the Veteran has PTSD.  The Board acknowledges, as noted above, that the record contains medical opinions to the effect that the Veteran does not have (or that there is insufficient information to conclude that he has) PTSD.  However, two of those opinions (in June 2012 and August 2012) were based, in large part, on an interpretation of psychological testing that did not take into account the Veteran's limited intellectual functioning, as reflected by the results of WAIS-IV testing by Dr. Adkins in September 2012 and, later, by a VA examiner in July 2013.

Standing in contrast to the June 2012 and August 2012 opinions are opinions from no fewer than five health care professionals who have diagnosed PTSD.  Significantly, at least three of those providers (the Veteran's VA treating therapist and Drs. Johnson and Adkins) have opined-following consideration of factors such as the Veteran's educational level, intellectual functioning, and psychopathology, and their effect on psychological testing-that the Veteran does, in fact, have PTSD.  Although the July 2013 VA examiner also took those things into account, and reached a contrary conclusion, the Board finds that, based on consideration of all factors, the July 2013 opinion is no more probative than the other opinions that stand in support of the Veteran's claim.  The evidence pertaining to whether the Veteran currently has PTSD is, at least, in relative equipoise.

The Board also finds that the preponderance of the evidence fails to demonstrate that the Veteran's PTSD has improved.  The Board acknowledges that the July 2013 examiner concluded that the Veteran had only mild or transient psychiatric symptoms, with a GAF score of 65.  Significantly, however, the Veteran's VA therapist, who has been treating the Veteran for more than five years (since 2008), has specifically testified that the Veteran PTSD has not improved during that time and, in fact, has gotten worse.  The therapist has stated that the Veteran is unemployable as a result of service-related psychiatric symptomatology, that his prognosis is poor, and that his GAF score is 42.  Drs. Johnson and Adkins have offered similar assessments with respect to the Veteran's inability to work as a result of psychiatric symptoms, with recent GAF scores in the range of 38 to 48.  Under the circumstances, the Board cannot conclude that the greater weight of the evidence reflects an improvement in the Veteran's impairment for functioning under the ordinary conditions of life and work as a result of service-related psychiatric symptomatology.

In the final analysis, and taking into consideration the totality of the evidence, the Board finds that the reduction in the evaluation for the Veteran's PTSD was not proper.  The evidence, at a minimum, gives rise to a reasonable doubt on the question.  38 C.F.R. §§ 3.103, 4.2 (2013).  Accordingly, restoration of the 100 percent rating for PTSD is granted, effective the date of reduction, July 1, 2013.


ORDER

Restoration of the 100 percent rating for PTSD is granted effective July 1, 2013, subject to the law and regulations governing the award of monetary benefits.



____________________________________________
A. JAEGER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs