Citation Nr: 20042897 Decision Date: 06/25/20 Archive Date: 06/25/20 DOCKET NO. 17-67 044 DATE: June 25, 2020 ORDER Entitlement to service connection for hypertension is denied. Entitlement to an increased rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. The Veteran’s recurrent symptoms of elevated blood pressure were not incurred in or related to service; it did not manifest within one year of service. 2. The Veteran’s PTSD manifests in occupational and social impairment with deficiencies in most areas, with symptoms such as neglect of personal hygiene, anxiety, and limited social interactions. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2019). 2. The criteria for entitlement to an increased rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code (Code) 9411 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1980 to September 1982. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision by the Department of Veterans Affairs (VA). This case was remanded in January 2019 for further development. 1. Entitlement to service connection for hypertension. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases (including hypertension) will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent disabling within one year after service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. If a chronic disease enumerated in 38 U.S.C. § 1101(a) or 38 C.F.R. § 3.309 is diagnosed after separation from service, the nexus requirement of a claim for service connection can be proven by evidence of a continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA must provide a medical examination or opinion when the record contains (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that remand for a VA examination is unnecessary. While the record indicates a history of hypertension or elevated blood pressure, see e.g., December 2015 VA treatment records, the Veteran has not submitted evidence, including lay evidence, that the disease was incurred in service, incurred within one year of service, or is otherwise related to service. While there are blood pressure readings in service, see, e.g., undated service treatment records, there is no indication that such blood pressure readings were elevated or otherwise indicative of hypertension. Indeed, VA treatment records indicate the Veteran’s current symptoms may be related to non-service-connected obstructive sleep apnea. See July 2012 VA treatment records. Because there is no evidence establishing that an event, injury, or disease occurred in service or establishing hypertension manifested one year after service, and there is no indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service, remand for a VA examination is unnecessary. As discussed, there is no evidence of in-service incurrence, incurrence within one year of service, nor any relation of the Veteran’s hypertension or elevated blood pressure to service. As a result, service connection is not warranted, and the matter must be denied. 2. Entitlement to an increased rating in excess of 70 percent for PTSD. The Veteran’s PTSD is currently rated at 70 percent under the General Rating Formula for Mental Disorders (General Formula). A 70 percent evaluation is warranted where there is occupational and social impairment, with deficiencies in most areas (such as work, school, family relations, judgment, thinking, or mood). This may be 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); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Code 9411. A 100 percent evaluation is warranted for total occupational and social impairment. This may be 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; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the General Formula is not intended to constitute an exhaustive list, but provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, 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 (Fed. Cir. 2013). Furthermore, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. As relevant to this case, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), states that it was recommended that the use of Global Assessment of Functioning (GAF) scores be dropped for several reasons, including their conceptual lack of clarity and questionable psychometrics in routine practice. The Board recognizes the Court’s holding in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) regarding the importance of GAF scores, however, as the medical community has determined that GAF scores are an unreliable measure of a psychiatric disability, the Board assigns the GAF scores mentioned in the record no probative value, and will not discuss them specifically. See also Golden v. Shulkin, 29 Vet, App. 221 (2018). During a July 2013 VA examination, the Veteran reported that her relationship with her husband and children was good. She had friends in her life but mostly did activities with her best friend and husband. She did not go out much because she felt better staying home. Her friend indicated that the Veteran did not form new relationships easily due to her distrust of others, especially men. The examiner opined the Veteran had occupational and social impairment with reduced reliability and productivity and noted that the Veteran had panic attacks when she had to go to the hospital. Her memory was poor for numbers and concentration was poor. In December 2013, the Veteran’s friend reported that she could not be alone with strange men and could not drive in crowds or under any stress. She was afraid of strangers and could not handle authority at all. When approached by someone that she perceived could affect her life, she simply could not think. See December 2013 statement. During a February 2015 VA examination, the Veteran reported that her relationship with her husband was supportive, but she had no recent contact with her children. She stated that she could perform self-care and personal hygiene tasks independently, but that she had been increasingly neglecting bathing. She reported that she prepared meals and cleaned the home as tolerated but would sometimes neglect these activities if she did not feel physically or psychologically up to performing them. She reported that her husband did most shopping, but that she would sometimes shop at a nearby convenience store when it was not crowded. She indicated that if stores were too busy, she could not enter them because of anxiety. See February 2015 VA examination. The Veteran reported that most of her leisure time was spent at home, but she would occasionally visit a casino to play keno. She continued to experience panic attacks, characterized by feeling “hot and nervous” and lasting up to 45 minutes. She reported experiencing frequent perceptual disturbances during which she seemed to see movement at the periphery of her vision, described as “shadows.” She noted that she had a vision condition that would require surgery soon and that this might contribute to this experience. The examiner noted the Veteran was neglectful of personal appearance and hygiene and opined that she had occupational and social impairment with deficiencies in most areas. Id. In November 2016, a private physician opined the Veteran had occupational and social impairment with deficiencies in most areas. Her symptoms included obsessional rituals which interfered with routine activities, impaired impulse control, such as unprovoked irritability with periods of violence, persistent delusions or hallucinations, neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, and disorientation to time and place. See November 2016 Disability Benefits Questionnaire (DBQ). During an October 2017 VA examination, the examiner noted that the Veteran’s husband recently passed away and she was experiencing an increase in her PTSD symptoms as a result. The Veteran reported that she had good relationships with her husband’s brother and sister, and they were supportive of her. She planned to continue living with them until she was able to get her own place. She had a tense relationship with her mother-in-law. At that time, she experienced some limitations in her activities of daily living and her husband’s brother and sister reported that they did not have expectations for her to complete chores around the home. She continued to care for her service dog and had a few out of state friends that she spoke with a few times a week. The examiner noted that her symptoms included neglect of personal appearance and hygiene. In December 2017, the Veteran reported that she moved to her husband’s best friend’s home due to tensions while living with her mother-in-law. She continued to stay with him and trusted him very much. She had very little other social connection in the area. See December 2017 VA treatment records. In the summer of 2018, she reported that she was increasing social activities and traveling with friends. Although she was living with friends, she now wanted to live alone. She wanted to get back into cooking and hoped to take a pottery class. See June and July 2018 VA treatment records. After considering the competent evidence of record, the Board finds that the Veteran had occupational and social impairment with deficiencies in most areas. However, total occupational and social impairment was not shown at any time during the appeal period. Notably, nearly all of the VA examiners and the private physician opined that this was the Veteran’s impairment level, and none opined that the Veteran had total occupational and social impairment. The Board assigns significant probative weight to those opinions. Even if the Board were to assume that the Veteran had total occupational impairment, the record does not reflect total social impairment. While the Veteran reported intense anxiety around new people and panic attacks, she always had a small, close supportive network that included her husband, most of his family, or other friends, indicating that she is not totally socially impaired. Even when socially isolated after the death of her husband, she continued to maintain contact with friends out-of-state, reflecting that she has the ability to maintain social relationships that are otherwise not out of convenience, and she looked forward to events that required exposure to other people, such as taking a pottery class. Thus, the Veteran does not have total social impairment, and a 100 percent rating is not warranted. The Board notes that the Veteran is consistently noted to have difficulty with personal hygiene throughout the appeal period. Additionally, the November 2016 private physician noted several symptoms associated with a 100 percent rating in the rating criteria and the Veteran reported perceptual disturbances in February 2015. However, those symptoms do not reflect total social impairment and are outweighed by the evidence as discussed above, because they are infrequent. Moreover, the Veteran stated she had a vision condition that could account for the visual disturbances. Several of the symptoms noted by the November 2016 private physician are not reflected anywhere else in the record, to include when the Veteran’s symptoms worsened after the death of her husband. Thus, the Board assigns such symptoms little probative weight, and finds that the probative evidence of record reflecting no more than occupational and social impairment with deficiencies in most areas outweighs the evidence in support of finding that the Veteran had total social impairment. Because the evidence reflects that the Veteran had occupational and social impairment with deficiencies in most areas, a rating in excess of 70 percent is not warranted, and the matter must be denied. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Sandler, Associate Counsel 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.