Citation Nr: 21030926 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 17-13 676 DATE: May 20, 2021 REMANDED Entitlement to an increased rating for posttraumatic stress disorder (PTSD), evaluated as 50-percent disabling prior to February 13, 2021, and as 70-percent disabling since, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active duty for training from March to July 1994, and active duty from June 2004 to November 2005. He also had service in the National Guard. In September 2019, this Board denied a rating higher than 50 percent for the Veteran's PTSD and his derivative TDIU claim. He appealed the Board's decision to the higher U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC). In a January 2021 Order, the Court vacated the portion of the Board's decision denying a rating higher than 50 percent for the PTSD and remanded this claim back to the Board for further development and readjudication pursuant to agreement in a Joint Motion for Partial Remand (JMPR). To comply with the Court's Order, the Board, in turn, is remanding this claim back to the local Regional Office (RO) (Agency of Original Jurisdiction (AOJ)). With regard to the derivative claim of entitlement to a TDIU, the JMPR agreed there was no error in denying this other claim, but that it nonetheless remains part and parcel of the claim for a higher rating for the PTSD because it is inextricably intertwined, therefore, still at issue in this appeal. In a February 2021 decision, so during the pendency of this appeal, the RO (AOJ) granted a higher 70 percent rating for the PTSD as of February 13, 2021. Thus, this appeal now concerns whether the Veteran was entitled to a rating higher than 50 percent prior to that date and whether he has been entitled to a rating higher than 70 percent since. This determinative issue of whether the Veteran is entitled to higher ratings may depend on whether his non-service-connected diagnosis of delusional parasitosis is related to his service-connected PTSD. Also, if it is not possible or feasible to distinguish what measure of his symptoms are attributable to one versus the other, this reasonable doubt will have to be resolved in his favor and, for all intents and purposes, all symptoms and impairment attributed to his service-connected PTSD. In November 2014, the Veteran was seen by VA (infectious disease) for a history of long-standing feeling of worms in his body and increased itching; the clinical impression was delusional parasitosis. He was admitted as a psychiatric in-patient for approximately five days in December 2014 to deal with his delusions about mold and parasites infecting his skin and picking disorder. A March 2015 VA record reflects the Veteran's belief that he has a fungal infection just under the surface of his skin with subsequent parasitic infestation that is eating the fungus, and his report that he has been spending most of his time working on his home to get it clean. The record also shows he reports "ongoing and highly disabling symptoms suggestive of a delusional disorder though he adamantly advocates for and believes that he has a significant skin condition. Anxiety and obsessionality regarding this belief have clearly led to an inability to function in any meaningful way, including employment. Increase in sertraline could be of benefit for anxiety, though ultimately finding an antipsychotic that can be used/tolerated at high dose is likely to be helpful. Again, complicating treatment is that he is not accepting of this as delusional." An April 2015 dermatology record shows the Veteran has a persistent rash that may be related to obsessive-compulsive disorder (OCD). He reported that he had moved out of his log cabin home because he was concerned about infestation and was fearful of spreading the infection to his girlfriend, so he had discontinued physical contact. He also reported being unable to work due to his skin disorder and having difficulty being out in public. An August 2015 Disability Benefits Questionnaire (DBQ) indicates the Veteran has a diagnosis of PTSD but also list a separate diagnosis of Delusional Disorder (Delusional Parasitosis), somatic type. The examiner opined that the two diagnoses are unrelated. The examiner also opined that the Veteran "is impaired both occupationally and socially, but it is by Delusional Parasitosis rather than PTSD". While the August 2015 DBQ examiner opined that the two disabilities are unrelated, she did not provide any rationale for her opinion. The Veteran contends there may be a relationship between his PTSD and delusional disorder and, as support for this proposition, has cited to an article. See his VA Form 9, Substantive Appeal to the Board, and the 2019 Informal Hearing Presentation (IHP) from his representative. The article by Dr. Gale E. Ridge, Delusory Parasitosis, The Belief of Being Lived on by Arthropods or Other Organisms, states there are at least four conditions that may trigger delusional parasitosis: environmental (to include cleaning products, mold, pollen), medical (including PTSD), drug side effects, and commonly encountered insects and arachnids. There have been several possible reasons noted in the clinical records for the Veteran's paranoid delusions: a change in Synthroid medication, diet pills, his typical coping mechanisms are less robust under stressful conditions, his father was paranoid schizophrenic, and/or auto-immune etiology. Clinical records dated in 2017 note the Veteran was "lost to follow-up in mental health clinic in 2015, last visit was 3/31/15." A February 2021 DBQ indicates the Veteran no longer meets the diagnostic criteria for Delusional Disorder. He said that "he works to deal with his past delusion regarding bugs." Based on this collective body of evidence, and with consideration of the JMPR (in which the contesting parties agreed that the Board had failed to adequately address the contentions of a relationship or correlation between the Veteran's PTSD and delusional parasitosis), the Board finds that medical comment concerning this may be useful in deciding this appeal. Accordingly, the claims are REMANDED for the following action: Obtain a supplemental opinion to the August 2015 and February 2021 DBQs. This includes providing rationale regarding the opinion in the 2015 DBQ that the Veteran's delusional parasitosis is not related to his PTSD. In providing this necessary rationale, the examiner must consider the pertinent evidence of record including especially: a) the November 2014, December 2014, March 2015, and April 2015 mental health and dermatology clinical records; b) the August 2015 DBQ; c) the article by Dr. Gale E. Ridge, Delusory Parasitosis, The Belief of Being Lived on by Arthropods or Other Organisms; d) the Veteran's change in Synthroid medication and use of diet pills; e) the Veteran's typical coping medications that have been found to be less robust under stressful conditions; f) the Veteran's family history of paranoid schizophrenic (his father); g) a possible auto-immune etiology; and h) the February 2021 DBQ. In the alternative, after reviewing that and all other relevant evidence, if the examiner finds that it is as likely as not (50 percent or greater probability) the Veteran's delusional parasitosis in 2014 and 2015 was caused OR aggravated by his PTSD, so related, the examiner should provide rationale for this conclusion. Regarding the latter, if the examiner finds that it is as likely as not the Veteran's PTSD aggravated (worsened) his delusional parasitosis, the examiner should, to the extent reasonably possible, discuss the baseline severity of the paranoid delusional disorder prior to any aggravation as it compares to the severity after aggravation, if any. When responding, regardless of whether favorably or instead unfavorably, it is essential the examiner provide rationale preferably citing to evidence in the file supporting conclusions and/or accepted medical authority. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Wishard 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.