Citation Nr: 20003449 Decision Date: 01/15/20 Archive Date: 01/14/20 DOCKET NO. 16-24 057 DATE: January 15, 2020 ORDER Entitlement to a rating of 70 percent, but no higher, for posttraumatic stress disorder is granted. REMANDED Entitlement to a rating in excess of 10 percent for coronary artery disease is remanded. Entitlement to a total disability rating based on individual unemployability is remanded. FINDING OF FACT The Veteran’s posttraumatic stress disorder is manifested by recurrent nightmares, impaired impulse control, neglect of personal appearance and hygiene, and difficulty adapting to stressful circumstances, all resulting in occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for a rating of 70 percent, but no higher, for posttraumatic stress disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1966 to January 1968. A videoconference hearing was held before the undersigned veterans law judge in September 2019. The transcript is of record. During the hearing, the VLJ clarified the issues, asked if there was outstanding evidence and held the file open for the submission of evidence. Such actions comply with 38 C.F.R. § 3.103. Entitlement to a rating of 70 percent, but no higher, for posttraumatic stress disorder Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. §§ 3.102, 4.3. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating greater than 50 percent. The Board concludes that the Veteran’s symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The Veteran received a VA examination in April 2015. At the examination he reported having an improving relationship with his son but a strained relationship with his daughter. He stated that he had a girlfriend of 7 years and only a few close friends. The examiner noted symptoms of depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and neglect of personal appearance and hygiene. Under the criteria for PTSD the examiner also noted symptoms such as irritable behavior and angry outbursts, reckless or self-destructive behavior, and persistent negative emotional state. At the hearing, the Veteran and his partner testified that the Veteran has recurrent nightmares, frequent angry outbursts, and only one close friend. The Veteran submitted an evaluation from a private psychologist in October 2019. During the evaluation the Veteran reported difficulty sleeping due to nightmares, hypervigilance, and angry outbursts including road rage. The examiner noted that the Veteran’s interpersonal functioning was poor, outside of his relationship with his partner. The examiner further observed that the Veteran’s memory was intact, insight was fair, judgment was poor and impulsivity moderate to high. He opined that the Veteran exhibits profoundly impaired interpersonal functioning and his ability to participate in even minor activities of daily living is profoundly curtailed. He noted that the Veteran’s partner handles bills, shopping, scheduling, and all other social interactions. Further, the Veteran has had difficulty maintaining continuity of care due to his struggles with interacting appropriately and scheduling providers. The Board finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 70 percent rating. The Veteran reported having recurrent nightmares, being depressed most of the time, having few to one close friend, and irritability resulting in unpredictable angry outbursts. Further, multiple examiners noted that he had difficulty in adapting to stressful circumstances and neglected personal appearance and hygiene. These symptoms reflect a level of impairment indicative of occupational and social impairment with deficiencies in most areas. While the Veteran did experience symptoms contemplated by a 100 percent rating—intermittent inability to perform acts of daily living—the evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. Further, while the Veteran had difficulty with planning and interacting in appropriate ways for appointments, the evidence shows he was not totally socially impaired. He continued to maintain a strong relationship with his partner, and he reported an improving relationship with his son. In short, the preponderance of the evidence weighs in favor of a finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 70 percent rating, but no higher. The criteria for a 100 percent or higher rating are not met, and a rating higher than 70 percent is not warranted. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for coronary artery disease is remanded. During his hearing, the Veteran asserted that his CAD has increased in severity since the Veteran was last examined by VA. Further, a treatment note from May 2016 states that the Veteran’s activity level is 4 METs. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of CAD. 2. Entitlement to a total disability rating based on individual unemployability is remanded. Because a decision on the remanded issue of an increased rating for CAD could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected CAD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Creegan The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.