Citation Nr: 18155889 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-49 927 DATE: December 6, 2018 ORDER Entitlement to an increased evaluation in excess of 50 percent for an acquired psychiatric disorder is denied. REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is remanded. Entitlement to an evaluation of total disability because of individual unemployability (TDIU) is remanded. FINDINGS OF FACT At no time during the period on appeal has the Veteran’s psychiatric symptomatology manifested in the level of severe dysfunction typified by the disability rating category of 70 percent under VA’s General Rating Formula for Mental Disorders. CONCLUSIONS OF LAW The criteria for entitlement to an increased evaluation in excess of 50 percent for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1155 (2012); 38 C.F.R. §§ 3.303, 4.130, diagnostic code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served from September 1970 to January 1972. He saw heavy combat in Vietnam. These claims come before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to an increased evaluation in excess of 50 percent an acquired psychiatric disorder is denied. The Veteran is currently evaluated as 50 percent disabled as the result of an acquired psychiatric disorder, previously diagnosed as posttraumatic stress disorder (PTSD). He seeks an increased rating. VA assigns disability ratings by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing the Veteran’s symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Psychiatric disabilities are evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130. Under that schedule: A psychiatric disability rated at 50 percent is typically characterized 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 (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. A psychiatric disability rated at 70 percent is typically characterized 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 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); and inability to establish and maintain effective relationships. As discussed below, the Veteran’s psychiatric disability, originally diagnosed as PTSD, was found in a May 2015 VSA PTSD examination to no longer reflect the full range of symptoms required for that diagnosis under the standards of the current edition of the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The examiner rendered a diagnosis of other specific trauma and stressors-related disorder. The Board has recharacterized the disorder to encompass the range of the diagnoses. At the same time, the Board notes that all psychiatric disorders, regardless of how they are characterized, are rated according to the same standards, in this case implicating the 50 percent and 70 percent rating categories described above. The Board notes that the above symptoms serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436 (2002). As the Veteran’s current disability rating is 50 percent, the question for the Board is whether at any time during the period on appeal the Veteran’s PTSD manifested in symptomatology demonstrating the level of severe dysfunction suggested by the symptoms in the 70 percent rating category. When awarding a 50 percent rating in November 2014, the Board noted that the Veteran had a restricted affect, daily intrusive thoughts of Vietnam, a preference for being alone, problems with irritability and anger outbursts, hypervigilance, problems feeling safe, and nighttime obsessional behavior in checking the locks on doors and windows and looking into the yard, leading to disrupted sleep. At the same time, the Board found that the Veteran did not demonstrate the level of symptomatology commensurate with a 70 percent rating. The Veteran applied for an increased PTSD rating in May 2015, and in September 2015 underwent a VA PTSD examination (he had undergone previous examinations in October 2009 and July 2013). Based on the symptoms endorsed by the Veteran, the examiner rendered a diagnosis of other specific trauma and stressors-related disorder. His symptomatology was characterized by mild and transient symptoms, which the Board notes are commensurate with a 10 percent rating. Noting, however, that the results of the one examination did not demonstrate the sustained improvement contemplated by VA regulations before a reduction in rating was justified, the September 2015 rating decision continued the Veteran’s 50 percent rating. The Board notes no evidence of record showing that the Veteran is deficient in most occupational and social areas, which as described above is the standard pertaining to a 70 percent disability rating. To the contrary, before retiring the Veteran had held a steady job with the same employer for over 18 years. At the time of the examination he had a steady marriage of over 37 years, which he described as “pretty good,” he endorsed being on good terms with his daughter, whom he saw daily, as well as with extended family and friends, and he appeared to engage in normal activities of daily living without substantial difficulty. The Board notes no evidence in the record suggesting, for example, that the Veteran experiences a near-continuous state of panic or depression that affects his ability to function independently, appropriately and effectively; or a neglect of personal hygiene; or an inability to establish and maintain effective relationships. Rather, as noted, the record shows that he established and continued to maintain effective work and family relationships. The Veteran simply does not demonstrate the level of severe dysfunction suggested by the criteria in the 70 percent category. In his September 2015 notice of disagreement, the Veteran relied on an April 2009 psychological examination and opinion, and subsequent letters of support, provided by L.G., M.A., LPA, his long-time treating licensed psychological associate, to argue that his PTSD disability rating should be either 70 percent or 100 percent. The Veteran reported seeing L.G. once every couple of months, and he has been seeing her since 2009. In her April 2009 examination, L.G. diagnosed PTSD, and opined that the Veteran had memory and concentration problems, and was so severely compromised in his ability to initiate or sustain work or social relationships, that he was totally and permanently disabled. The Board notes, however, that in her opinion, L.G. offered not a single example of his memory and concentration problems, no discussion whatsoever about the Veteran’s work, and little discussion of the Veteran’s social relationships, including the fact that at that point he had been married for over 30 years or any other details of family life other than his feeling that his adult daughter took safety for granted. The Board finds this analysis incomplete and conclusory, and consequently affords it little probative weight. An adequate rationale must be provided for any medical opinion rendered; a conclusory, contradictory or incomplete analysis is not adequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007). L.G.’s March 2014 letter of support did contain examples of the impacts of the Veteran’s symptoms on his daily functioning. The Board provided a 50 percent disability rating for the Veteran’s PTSD in November 2014. The letters dated May 2015 and August 2015, however, each contain one substantive paragraph reporting the Veteran’s current symptoms without discussing the occupational or social impairment resulting from those symptoms, and as a result they are of limited probative value for judging the severity of the Veteran’s disability. Stefl, 21 Vet. App. 120. In her initial PTSD diagnosis, L.G. attributed to the Veteran a global assessment of functioning (GAF) score of 37, which did not change in succeeding letters of support. The Board notes that GAF is a summary convention utilized by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) to represent the clinician’s judgment of the patient’s overall level of functioning. Although the current version of the DSM no longer uses GAF, the Board notes that while in use a GAF rating of 37 represented a very low score implying impairment in reality testing or communication (e.g., obscure or irrelevant speech) or a major impairment in several areas of living (e.g., neglect of family and inability to work). As noted above, the Board sees no objective evidence in the claims file of the level of severe functional impairment implied by the attributed GAF score of 37, and as L.G. offered no explanation or rationale for her GAF evaluation, the Board affords it little probative value. A medical opinion containing only data and conclusions is not entitled to any weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). By contrast, the Board affords significant probative weight to the results of the September 2015 VA PTSD examination, which comprised a full review of the Veteran’s claims file, an in-person clinical interview, the administration of additional screening tools and a specific discussion of the inadequacy and error of L.G.’s attribution of a GAF of 37. The examiner noted that in the clinical interview, the Veteran no longer endorsed symptoms that would qualify for the formal diagnosis of PTSD. She indicated that at the time of the examination the Veteran demonstrated mild, sub-PTSD psychiatric symptoms. The Board notes, however, that the Veteran’s 50 percent PTSD evaluation was granted as of July 2009. As the rating has been in place for more than five years, and in light of the Veteran’s reports to L.G. of ongoing PTSD symptoms, the Board declines to find sustained improvement in the Veteran’s PTSD. Finally, the Board notes that the Veteran has not submitted evidence or discussion demonstrating actual functional impairment typical of the 70 percent rating category. A claimant has the responsibility of presenting and supporting a claim for disability benefits. 38 U.S.C. § 5107. In light of the above, the Board finds that entitlement to an increased evaluation in excess of 50 percent for an acquired psychiatric disorder is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is remanded. The Veteran filed his claim for hypertension in October 2015. In February 2016, VA obtained a medical opinion addressing whether his diagnosed hypertension was caused or exacerbated by his PTSD medication. In a single sentence opinion, the medical examiner opined that the Veteran’s hypertension was neither caused nor aggravated by his PTSD medication because that medication “[was] not associated with causing or aggravating his condition.” The examiner offered no further rationale, medical information or citation to medical authority to explain what is otherwise a tautology. An adequate rationale must be provided for any medical opinion rendered; a conclusory, contradictory or incomplete analysis is not adequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007). Thus, the Board finds this opinion inadequate for rating purposes and will remand for another opinion, including whether the hypertension was caused or aggravated by the PTSD itself. In support of his claim, the Veteran submitted a statement from a private physician opining that it was as likely as not that the Veteran’s PTSD “contributes to” his hypertension, as well as an article from a medical journal discussing a study of the relationship between PTSD and the incidence of hypertension. The Board notes that the physician’s opinion was also one sentence, does not indicate whether the PTSD caused or aggravated the hypertension, and is unsupported by further rationale or citation. Hence, it is afforded no weight. Nieves-Rodriguez, supra, 22 Vet. App. at 304. The Board notes that the article discussing the study is general in nature, and does not contribute to an evaluation of the specific etiology of the Veteran’s disease. As such, further development is necessary to determine the likely nature and etiology of the Veteran’s diagnosed hypertension. 2. Entitlement to TDIU is remanded. Two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered. Because a decision on the remanded issue of service connection for hypertension could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is therefore required as well. The matter is REMANDED for the following action: 1. Undertake appropriate efforts to obtain any relevant outstanding VA or private medical records, and associate them with the claims file. 2. Thereafter, obtain an addendum opinion from an appropriate medical examiner to determine whether the Veteran’s hypertension is causally or etiologically related to the Veteran’s PTSD medication. The Veteran’s claims file must be provided to the examiner and the examiner should note his or her review of the file. If the examiner deems a physical examination of the Veteran necessary in order to provide the requested opinion, one should be provided. In the event of an examination, the examiner must obtain a detailed clinical history from the Veteran. All pertinent pathology found on examination must be noted in the report of the evaluation. Any testing deemed necessary must be performed. 3. The examiner should provide an addendum opinion answering the following: (a) Was the Veteran’s hypertension at least as likely as not (50 percent or greater probability) incurred in or caused by active military service? (b) Is it at least as likely as not that the Veteran’s hypertension is proximately due to, or the result of, the Veteran’s PTSD, to include any prescribed medications? (c) Is it at least as likely as not that the Veteran’s hypertension has been aggravated (i.e. worsened beyond the natural progress) by the Veteran’s PTSD, to include any prescribed medications? (d) If aggravation is found, the examiner should also identify and describe the following medical issues: i. The baseline manifestations of the hypertension existing prior to aggravation by the Veteran’s PTSD or prescribed medications; and ii. The increased manifestations which, in the examiner’s opinion, are due to the Veteran’s PTSD or prescribed medications. “Aggravated” in this context means a persistent worsening of the underlying condition, as opposed to a temporary or intermittent flare-up of symptomatology which then resolves to the baseline level. The examiner is advised that the Veteran is competent to report history and symptoms and that those reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran’s reports, the examiner must provide a rationale for doing so. A complete rationale must be given for all opinions and conclusions expressed. If it is not possible to provide a requested opinion without resorting to speculation, the examiner should state why speculation would be required (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist’s opinion or other information needed to provide the requested opinion. K. A. KENNERLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David S. Katz, Associate Counsel