Citation Nr: 18146532 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 12-13 200 DATE: October 31, 2018 ORDER An initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) prior to March 7, 2014, and higher than 50 percent thereafter, is denied. REMANDED Service connection for hypertension is remanded. FINDING OF FACT Prior to March 7, 2014, PTSD was manifested by nightmares, chronic sleep impairment, periods of depression, and difficulty with trust, with additional periods of minimal symptoms; from March 7, 2014, PTSD was manifested by mood disturbances, anxiety, mild memory loss, and difficulty in establishing and maintaining relationships. CONCLUSION OF LAW The criteria for an initial rating for PTSD higher than 30 percent prior to March 7, 2014, and higher than 50 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the U.S. Army from February 1967 to September 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from December 2009 and April 2012 rating decisions. Initial rating for PTSD 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. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The assignment of different disability ratings at different times over the life of the claim, a practice known as a “staged rating,” is appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App 119 (1999). The Veteran’s PTSD is rated under Diagnostic Code 9411, which is part of the General Rating Formula for Mental Disorders found in 38 C.F.R. § 4.130. Under that Formula, a 30 percent evaluation contemplates 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, or mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation is warranted where the disorder is manifested by 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 for example, 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. A 70 percent evaluation is warranted where the disorder is manifested by 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 that is 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 work-like setting; and an inability to establish and maintain effective relationships. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: 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 and place; memory loss for names of close relatives, own occupation, or own name. A veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114 (Fed. Cir. 2013). Symptoms listed in the General Rating Formula serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. They are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). A. Prior to March 7, 2014 During this period, the Veteran has been assigned a 30 percent rating, and the Board finds that a higher rating is not warranted. Initially, the Board recognizes that during a March 2011 VA examination, the Veteran reported significant problems with his son, who was living with him and his wife at the time. He stated that his son had uncontrolled behavioral problems, including explosive outbursts and damaging property. He admitted that he and his wife were afraid of that his son could kill them in their sleep. The examiner documented that the Veteran’s symptoms of worry, anger, nervousness, irritability and suicidal ideation were attributable to this situation. Symptoms unrelated to the Veteran’s son included nightmares, difficulty trusting others, feeling tired and down, and poor concentration. The Veteran indicated that his periods of depression lasted a matter of days. Otherwise, he denied any problems getting along with people, except those who “like to rule his roost.” He reported getting along well with his wife. He also had all kinds of friends and enjoyed hunting and fishing with them. He reported that he enjoyed his job and denied any problems with occupational functioning, except for difficulties related to his hearing. On examination, he was appropriately dressed. Depression was present. The Veteran reported a slight disorientation to time (one or two days) and mild short-term memory trouble. He also reported a history of auditory hallucinations in the form of voices that had occurred four or five times previously. Otherwise, he had no delusions, obsessive behavior, impaired impulse control, or problems with speech. The above findings are consistent with the assigned 30 percent rating. The Veteran’s sleep impairment, mild memory loss, depressed mood, and difficulty with trust (suspiciousness) are all expressly contemplated by the criteria for the 30 percent rating. Moreover, except as it pertained to his son, his social and occupational functioning was intact as he reported good relationships with others and no problems at his job. Although he reported auditory hallucinations, there were only four or five instances of this historically, which is not of sufficient frequency or duration to warrant a higher rating. There is also no indication that these hallucinations, or the Veteran’s slight time disorientation, affected his social or occupational functioning. In addition, there was no indication of panic attacks, long-term memory impairment, speech abnormalities, difficulty establishing and maintaining relationships, or other symptoms consistent with the higher 50 percent rating. In a May 2012 statement, the Veteran described symptoms which included auditory hallucinations, severe depression, panic attacks and suicidal ideation. However, the Board does not find his statement to be persuasive when weighed against the contemporaneous medical records. Specifically, February 2012 VA records show the Veteran denied any suicidal ideation, or significant depression or anxiety. Private records from September 2012 show the Veteran denied a stressed lifestyle or abnormal behavior, and his mood and affect were normal on examination. In sum, the overall impairment from the Veteran’s PTSD is consistent with no more than the currently assigned 30 percent rating during this period. b. From March 7, 2014 During this period, the Veteran is assigned a 50 percent rating for his PTSD, and the Board concludes that a higher rating is not warranted. In a statement received on March 7, the Veteran reported symptoms of nightmares, depression, anxiety, flashbacks and irritability. Notably, these symptoms are expressly contemplated by the criteria for the 50 percent rating. He also reported secluding himself from others. Nevertheless, VA records from July 2014 include a PTSD screen in which the Veteran denied any nightmares, avoidance, feeling on guard, or feelings of detachment. He underwent another VA examination in September 2015. The examiner noted that there was little change from the 2011 VA examination, except that the Veteran’s son was now doing much better. Otherwise, the Veteran reported that he had limited time for social activity due to work, which he still enjoyed. The examiner noted the presence of depressed mood, anxiety, chronic sleep impairment, intrusive thoughts, mild memory loss, disturbances in mood, and difficulty establishing and maintaining effective relationships. These symptoms are all expressly contemplated by the 50 percent rating assigned for this period. In an October 2015 statement, the Veteran reported that he had symptoms of suicidal ideation, obsessional rituals, a near-continuous panic and depression, unprovoked irritability, neglect of personal hygiene, and seclusion from others. However, the Board does not find this statement credible. First, no such symptoms were documented by the VA examiner one month earlier. Second, the Veteran’s statement includes a verbatim recitation of several of the rating criteria for the higher 70 percent rating and does not appear to be a genuine report of symptoms. Third, treatment records from May 2017 show the Veteran denied any suicidal ideation any admitted feeling depressed only on some days. Rucker v. Brown, 10 Vet. App. 67 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth to receive proper care). For these reasons, the Board finds that a rating higher than 50 percent is not warranted for this period. REASONS FOR REMAND Service connection for hypertension Service connection is warranted for a disability which is proximately due to, aggravated by, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The Veteran is service-connected for ischemic heart disease with atrial fibrillation. During an October 2017 VA examination for that disability, the VA examiner stated that it “also affects his blood pressure, which stays elevated more often than not.” This opinion raises the possibility that hypertension may be secondary to ischemic heart disease with atrial fibrillation, but it does include an adequate rationale to establish such a connection. Therefore, an addendum opinion is warranted. The matter is REMANDED for the following action: (Continued on the next page)   Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not proximately due to service-connected ischemic heart disease with atrial fibrillation, or aggravated beyond its natural progression by service-connected ischemic heart disease with atrial fibrillation. M. TENNER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Shamil Patel, Counsel