Citation Nr: 9802714 Decision Date: 01/29/98 Archive Date: 04/14/98 DOCKET NO. 95-07 085 DATE On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to an increased evaluation for duodenal ulcer disease with associated colitis and generalized anxiety disorder, currently evaluated as 40 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his daughter ATTORNEY FOR THE BOARD J. McGovern, Associate Counsel INTRODUCTION The veteran had active service from September 1945 to June 1947 and from October 1950 to April 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the December 1994 rating decision of the Huntington, West Virginia Department of Veterans Affairs (VA) Regional Office (RO), which denied an increased evaluation for duodenal ulcer disease with associated colitis and generalized anxiety disorder. By rating decision dated in September 1995, the RO determined that new and material evidence had not been submitted to reopen the claims for service connection for arthritis and myasthenia gravis. The RO also denied entitlement to service connection for hypertension, claimed as secondary to the service-connected duodenal ulcer with associated colitis and anxiety. In a January 1996 treatment record, S. Resheed, M.D., noted that he believed that the veteran had myasthenia gravis while in the service and stated that the veteran's myasthenia gravis was most likely service-connected. In a January 1996 statement in support of claim, the veteran stated that he was "filing for an increase" in the evaluation of allegedly service-connected conditions which included myasthenia gravis, hypertension, and arthritis. The Board notes that the veteran's January 1996 statement constitutes a sufficient notice of disagreement with respect to the issues of whether new and material evidence had not been submitted to reopen the claims for service connection for arthritis and myasthenia gravis and entitlement to service connection for hypertension, claimed as secondary to the service-connected duodenal ulcer with associated colitis and anxiety. Therefore, the RO should develop these issues accordingly. In an October 1995 statement in support of claim, the veteran asserted that an increased evaluation was warranted for his "service-connected skin condition." He asserted that he continued to have recurring episodes of "this skin condition." It appears that the RO considered this to be a claim for an increased rating for a scar of the penis and developed the claim accordingly. The Board notes that, in a January 1950 rating decision, the RO granted service connection for urticaria for outpatient treatment purposes. Additionally, by rating decision dated in May 1958, the RO granted service connection for chronic colitis due to E. histolytica with associated urticaria and assigned a zero percent evaluation, effective from April 1953. The Board notes that the veteran may be seeking an increased evaluation for urticaria and this matter is referred to the RO for appropriate development. By rating decision dated in November 1995, the RO denied entitlement to an increased evaluation for scars of the penis. The RO informed the veteran of this determination in November 1995. The veteran filed a notice of disagreement with that rating decision in December 1995 and, in March 1996, the RO issued a statement of the case which addressed the issue of entitlement to an increased evaluation for scars of the penis. As the veteran did not file a timely substantive appeal, this issue was not finalized for appellate review. In the introduction of the November 1996 remand, the Board noted that the veteran had raised the issue of entitlement to an increased rating for scars of the penis in a January 1996 statement and referred the issue of entitlement to an increased evaluation for scars of the penis to the RO for appropriate development. By rating decision dated in June 1997, the RO again denied an increased evaluation for scars of the penis. By letter dated later in June 1997, the RO informed the veteran of this determination. In an August 1997 VA Form 9, Appeal to Board of Veterans' Appeals, the veteran stated that he was replying to "315/211A" and that he wished to appeal his case. The Board notes that both the letter informing the veteran of the June 1997 rating decision and a June 1997 cover letter attached to a supplemental statement of the case which addressed unrelated issues included the notation "In Reply Refer To: 315/211A." Therefore, it is unclear whether the veteran intended to express disagreement with the June 1997 denial of an increased evaluation for scars of the penis. This matter is referred to the RO for clarification as to whether the veteran intended to appeal this issue and any appropriate development. In a January 1996 statement in support of claim, the veteran stated that he was "filing for an increase" in the evaluation of a number of allegedly service-connected conditions which included angina pectoris. The RO had previously denied service connection for a heart condition in an unappealed rating decision dated in June 1990. The veteran was informed of this determination by letter dated in July 1990 and the rating decision became final in July 1991. The Board notes that it appears that the veteran may be attempting to reopen the claim for service connection for a heart disorder and this matter is referred to the RO for appropriate action. The March 1996 VA psychiatric examiner noted that the veteran was not a candidate for rehabilitation or gainful employment due to his age and physical and emotional condition. At the January 1997 VA psychiatric examination, the examiner noted that the veteran had chronic recurrent anxiety and depression, that his physical problems contributed to his nervousness and depression, and that a combination of his physical and psychiatric impairments made him disabled from being gainfully employed. In the December 1997 informal hearing presentation, the representative asserted that the January 1997 VA psychiatric examination report constitutes an informal claim for a total disability rating based on individual unemployability. The RO has not addressed the issue of entitlement to a total rating based on individual unemployability and this matter is referred to the RO for appropriate development. At the June 1996 hearing before a member of the Board held at the RO, the veteran appeared to assert that his nervous condition caused or aggravated his myasthenia gravis. Hearing Transcript (Tr) at 15. The Board notes that the veteran may be claiming entitlement to service connection for myasthenia gravis or other disorders, claimed as secondary to his service-connected generalized anxiety disorder. This matter is referred to the RO for clarification as to whether the veteran is making such a claim and, if so, for appropriate development. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his duodenal ulcer disease with associated colitis and generalized anxiety disorder is more disabling than the current 40 percent evaluation reflects, thereby warranting an increased evaluation. With respect to his generalized anxiety disorder, he asserts that he has anxiety, nervousness, edginess, tension, depression, social isolation when depressed, anger, dislike of crowds, irritability, panic, shakiness, difficulty getting along with people, lack of patience, insomnia, frustration, nightmares, startle response, intrusive thoughts, and flashbacks. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence favors a separate 30 percent evaluation for generalized anxiety disorder. It is also the decision of the Board that further development is necessary with respect to the issue of entitlement to an evaluation in excess of 40 percent for duodenal ulcer disease with colitis. FINDINGS OF FACT 1. All evidence necessary for an equitable adjudication of the issue on appeal has been obtained. 2. The veteran's generalized anxiety disorder results in definite, but no more than definite, social and industrial impairment as contemplated by the applicable rating criteria in effect prior to November 7, 1996. 3. Under the applicable rating criteria effective November 7, 1996, the veteran's anxiety disorder results in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for a separate 30 percent evaluation for generalized anxiety disorder have been met. 38 U.S.C.A. 1155, 5107 (West 1991); 38 C.F.R. Part 4, 4.14, 4.25, 4.132, Diagnostic Code 9400 (1996); 61 Fed. Reg. 52695-52702 (October 8, 1996) (to be codified at 38 C.F.R. 4.130, Diagnostic Code 9400); Esteban v. Brown, 6 Vet. App. 259 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim is well grounded within the meaning of 38 U.S.C.A. 5107. A well-grounded claim is a plausible claim which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In general an allegation of an increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). In November 1996, the Board remanded this case to the RO for further development to include obtaining additional treatment records, affording the veteran a VA psychiatric examination, and consideration of the new diagnostic criteria for mental disorders effective from November 7, 1996. The veteran has not asserted that any records of probative value regarding his generalized anxiety disorder which are not already associated with his claims folder are available. The Board is satisfied that all relevant facts regarding the claim for an increased rating for generalized anxiety disorder have been properly developed and that no further assistance to the veteran is required in order to comply with the duty to assist him as mandated by 38 U.S.C.A. 5107. Initially, the Board notes that the evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Dyspnea, tachycardia, nervousness, fatigability, etc., may result from many causes; some may be service connected, others, not. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. 4.14 (1996). The United States Court of Veterans Appeals (Court) has emphasized that all disabilities, including those arising out of a single disease entity, are to be rated separately as long as the symptomatology is not duplicative or overlapping. Esteban v. Brown, 6 Vet. App. 259 (1994); 38 C.F.R. 4.25. With respect to the anti-pyramiding provision, the Court stated that the critical element in determining whether a veteran's disabilities may be rated separately is whether any of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other conditions. Esteban, 6 Vet. App. at 262. Ratings under diagnostic codes 7301 to 7329, inclusive should not be combined with each other. 38 C.F.R. 4.114 (1996). A single evaluation will be assigned under the diagnostic code which reflects the predominant disability,picture with elevation to the next higher evaluation where the severity of the overall disability warrants such an elevation. Id. Therefore, the veteran's service- connected duodenal ulcer disease, evaluated under 38 C.F.R. 4.114, Diagnostic Code 7305 (1996), and colitis, evaluated pursuant to 38 C.F.R. 4.114, Diagnostic Codes 7319, 7323 (1996), may not be evaluated separately. The Board notes that the veteran's duodenal ulcer disease, with associated colitis and generalized anxiety disorder is currently evaluated as 40 percent disabling under 38 C.F.R. 4.114, Diagnostic Code 7305 which addresses only duodenal ulcers. However, the evidence reveals non-overlapping manifestations of duodenal ulcer disease with colitis and generalized anxiety disorder which are capable of being separately rated. The veteran's generalized anxiety disorder is ratable as a separate disability, because it has separate and distinct manifestations not encompassed by the 40 percent evaluation for duodenal ulcer disease with colitis. See 38 C.F.R. 4.14, 4.25; Esteban. Thus separate ratings are warranted for duodenal ulcer disease with colitis and generalized anxiety disorder and these disorders will be evaluated separately. As noted above, the issue of entitlement to an increased evaluation for duodenal ulcer disease with colitis will be addressed in the remand portion of this decision. Factual Background The service medical records reveal that the veteran was treated for anxiety and nervousness during his second period of service. A December 1952 psychiatric consultation report reveals that the veteran complained of nervousness and anxiety and that he reported that he had episodes during which he felt frightened and had palpitations, excessive perspiration, and restlessness. The examiner noted that he believed that the veteran was sufficiently disturbed emotionally to somewhat impair his fitness for duty and that the psychological factors had been partly responsible for the veteran's peptic ulcer. The diagnosis was psychogenic gastrointestinal reaction. In April 1953, the veteran was discharged by reason of physical disability. By rating decision dated in April 1953, the RO granted service connection for duodenal ulcer, chronic, activity undetermined, with associated anxiety, and awarded a 20 percent evaluation effective from April 1953. A VA Form 5-3831a, Employee Health Record, which shows treatment from March 1954 to May 1974, reveals that the veteran received treatment for nervousness. At a June 1954 VA examination, the veteran reported that he did not sleep well at night which he seemed to relate to his stomach and ulcer problems. The examiner noted that the nervous system was normal. There was no relevant diagnosis. The veteran was hospitalized from December 1961 to January 1962 for unrelated illnesses and the examiner noted that the veteran was cooperative and mentally alert. An October 1971 examination report from the West Virginia Department of Welfare, Division of Vocational Rehabilitation, included a diagnosis of anxiety tension state. By letter dated in November 1971, M. G. MacAulay, M.D., reported that he evaluated the veteran in October 1971. Dr. MacAulay noted that the veteran was currently taking a tranquilizer, Meprobamate. It was noted that the veteran was anxious to improve his income status and that he was attending night school. Dr. MacAulay stated that the veteran was an intelligent and verbal individual, that he was not acutely disturbed from a psychiatric standpoint, and that he had had anxiety symptoms for a number of years. There was no diagnosis. A VA hospital summary shows that the veteran was hospitalized from January 1973 to February 1973. The diagnoses included severe anxiety and nervousness. A July 1974 notification of personnel action form reveals that the veteran was placed on disability retirement due to progressive muscle weakness due to myasthenia gravis and back strain. A January 1989 VA hospital record shows that, when the veteran came in for medication refills, he complained of nervousness and appeared anxious. There was no diagnosis. Treatment records dated from February 1989 to March 1992 reveal complaints of nervousness and that the veteran was taking Valium. The diagnoses included history of hysterical reaction and hysteria. The veteran was hospitalized at a VA hospital from June 1989 to July 1989 and the relevant discharge summary diagnosis was acute hysterical reaction, recurrent episodes, stabilized; and hypertension and transient psychosis, resolved. The examiner noted that the veteran "refused" any evidence of mental problems on questioning. The examiner reported that the veteran was alert and well oriented to person, place, and time. It was noted that, during his hospitalization, the veteran had several panicky hysterical reactions, that he underwent a psychiatric consultation, and that the diagnosis of hysteria was confirmed. VA mental health clinic progress notes dated from August 1989 to March 1993 reveal that the veteran continued to seek treatment complaining of nervousness, cc nerves," frustration, flashbacks, and excitability. A September 1989 VA mental health intake record reveals that the veteran had several complaints which included marked nervousness. The examiner noted that the veteran was neat in appearance; that he spoke quite well; that he endeavored to be cooperative, attentive, and polite; that there was a logical progression in the association of ideas; that he had no suicidal ideation; and that he did not have any delusional trends of thought or hallucinatory experiences. The examiner reported that the veteran was well oriented to time, place, and person; that his memory for recent and past events was unimpaired; that he gave a good account of himself, that he had insight into his condition; and that his judgment was not impaired. The pertinent diagnosis was post-traumatic stress disorder (PTSD), passive personality disorder, severe psychosocial stressors, and poor adaptive functioning. At a May 1991 VA rating examination conducted by a private consultant, the veteran reported that he was shaky, that he had nervous energy and sweating, and that his stomach got upset. The veteran reported that he became nervous, anxious and loud. He stated that when he tried to do something that he couldn't, he got nervous, sweaty, and very frustrated. He reported that he slept well but that he had nightmares about the war. He related that, at times, he still became hyperactive, overly energetic, and spoke louder and louder until his wife told him not to speak so loudly. He reported that his ulcers flared up when he got too nervous. The examiner noted that the veteran had marked psychomotor agitation and a prevailing sense of helplessness. It was noted that the veteran had no active suicidal or homicidal ideation. The examiner noted that the veteran retired on disability in 1974, that he had been married for 38 years, that his relationship with his wife was fair, and that he had three children. The examiner reported that the veteran was neat, tidy, and cooperative; that he was oriented for time, date, place, and person; that his speech was clear, rational, and appropriate; and that no evidence of psychosis or thought disorder was elicited. The examiner noted that the veteran was able to recall seven digits forward and five digits backward; that he was able to subtract 33 cents from a dollar; that he was able to remember a name and address after two and five minutes; that no clinical evidence of organicity was noted; and that his abstract thinking was poor. The examiner stated that the veteran appeared to be in the dull normal range of intelligence clinically despite his education and that insight, judgment, and problem solving seemed to be fair. The veteran reported that he lived with his wife, that he stayed active to the best of his ability, that he went to church regularly, that he had no particular hobbies or interests, and that he did not belong to any clubs or organizations. The relevant diagnosis was generalized anxiety disorder, recurrent, moderate to moderately severe, chronic in nature. By rating decision dated in June 1991, the RO increased the evaluation of the veteran's service-connected duodenal ulcer with associated colitis and generalized anxiety disorder to 40 percent, effective from February 1989. At the March 1993 VA psychiatric examination, the veteran reported that his problems with his nerves began in 1952 or 1953. He reported that he finished his GED, that he attended two semesters of college, that he worked for the VA as a radiology technologist from 1953 to 1974, and that he also worked as an elevator operator for a short period of time. He stated that when his nerves got bad his ulcers got bad. The veteran complained of recurrent nightmares. He stated that when he was nervous, he got mixed up, had nervous energy, had to do things right, and "had to struggle with what he had to do." He reported that he became upset when he could not do things right and that he had to have things in an orderly fashion. The veteran stated that it helped when he was working because it took his mind off of several things but that since he had retired he had had more problems with his nerves. He related becoming depressed due to his physical problems, that he had a tendency to worry, and that, when things were not going well, he got depressed, irritated, and easily frustrated. The examiner noted that the veteran had rather rambling speech, was circumstantial, and had difficulty organizing his thinking. The veteran was well oriented to person, place, and time; there was no evidence of any active hallucinations or delusions; his attention and concentration was normal; he was able to do routine calculations, serial sevens, and give the days of the week in reverse order; his memory and recall for recent events was slightly impaired; there was no evidence of looseness of association, flight of ideation, or pressured speech; and he denied being actively suicidal or homicidal. The examiner noted that the veteran appeared to be of above average intelligence and that his fund of knowledge was appropriate for his educational level and background. The pertinent impression was generalized anxiety disorder. The examiner commented that the veteran's generalized anxiety appeared to make his physical problems worse. In a May 1993 VA treatment record, the examiner noted that the veteran reported that he thought that his stomach disorder was caused by his nervous condition. There was no relevant diagnosis. A November 1993 treatment record reveals that the veteran complained of being "real nervous." There was no relevant diagnosis. Mental health progress notes dated from December 1993 to March 1994 reveal that the veteran complained of nervousness and edginess, nightmares of varying frequency, intrusive thoughts, flashbacks, startle response, some middle insomnia, varying mood with occasional depression, a tendency to isolate when depressed, and irritability. He stated that he believed that his anxiety contributed to his other medical problems. He also reported that he had a great deal of difficulty when things did not go just right; that he was a perfectionist and became nervous when things did not go his way; and that he had chronic depression secondary to his medical problems. The veteran reported that he had been hospitalized in 1989 or 1990 for anxiety and that he had been on Valium since that time. He denied any history of suicide attempts. The veteran stated that he had a history of assaultive behavior but that he had not had any physical altercations since 1960. The examiners noted that the veteran was pleasant and cooperative, that his eye contact was good, that his thoughts were goal-directed, that he denied any auditory or visual hallucinations or paranoid or grandiose delusions, that he was alert and oriented times three, that he was able to recall two of three items after five minutes and was able to name the president, that he was unable to spell world backwards, that he had no homicidal or suicidal ideation, and that there were no signs or symptoms of psychosis. The December 1993 examiner noted that there was some evidence of anxiety and some sedation and that, cognitively, the veteran was grossly intact in all spheres. The relevant diagnostic impressions were PTSD and PTSD, by history. In May 1994, the veteran sought treatment and complained that he became nervous and upset more easily. There was no relevant assessment. An August 1994 VA treatment record reveals that the veteran complained of anxiety and nervousness. The assessment included anxiety and PTSD. In a November 1994 treatment record, the examiner noted that the veteran continued to do rather poorly and complained that BuSpar medication had made him worse. The examiner noted that the veteran's family was extremely concerned and that he had done fairly well on Valium in the past. The examiner advised the veteran to stay on the least amount of Valium. Another November 1994 progress note revealed that the veteran was a little more nervous than when the examiner had last seen the veteran in April 1992. The veteran's daughter stated that he had had a little nervous problem in the past and it was noted that the veteran was being followed at the mental health clinic. A May 1995 VA mental health clinic treatment record reveals that the veteran continued to report that he became tense, anxious, and nervous. The veteran reported that his anxiety and depression were under much better control. The examiner noted that the veteran took medication for his psychiatric disorder; that he declined counseling stating that he was doing much better; that examiners recommended that the veteran increase his physical and social activities; and that the veteran had no suicidal or homicidal ideation. The examiner advised the veteran to be as psychosocially active as possible. In a July 1995 VA mental health clinic treatment record, the examiner noted that the veteran continued to do "fair" and that he became tense, anxious, and nervous. The veteran stated that Valium really helped him and the examiner advised the veteran to slowly reduce the Valium that he took. The relevant diagnosis was adjustment disorder with anxious and depressed mood secondary to physical illness and situational factors, and generalized anxiety disorder. The examiner advised the veteran to increase his physical and social activities and to be as active as possible psychosocially. It was noted that his family was fairly supportive. An October 1995 VA mental health clinic outpatient treatment record reveals that the veteran continued to do poorly and that he was tense, anxious, and depressed. The veteran stated that he was "just weak and tired." It was noted that he had been weaned off Valium, that he wanted to start using it again, and that the examiner discouraged this. The pertinent diagnosis was generalized anxiety disorder and adjustment disorder with anxious and depressed mood, secondary to physical and situational factors. In a January 1996 treatment record which primarily addressed an unrelated disorder, S. Resheed, M.D., noted that the veteran was being treated for PTSD. The diagnoses included PTSD. At a March 1996 VA examination, the veteran reported that, after his discharge from active service, he worked at the Beckley, West Virginia VA Medical Center (MC) from 1953 until "until his disability in 1974." He reportedly also worked at Raleigh Community Action in the janitorial service and attended Beckley College "until my myasthenia gravis hit me." The veteran reported that he had been hospitalized three to four times in service and at the Beckley VA hospital in 1989 when he had been extremely tense and anxious and his heartbeat was racing. The veteran asserted that he was frustrated, depressed, and anxious. He stated that he had nightmares, that loud noises affected him, that he could not cope, that people did not understand him, and that he had "so many problems." The examiner noted that the veteran had been married for approximately 40 years and that he had three grown children. The examiner reported that the veteran was neat, tidy, and cooperative and that he spoke clearly, audibly, and rationally. ne examiner stated that the veteran's mood had been rather labile; that he was oriented to time, place, date, and person; that no evidence of psychosis or thought disorder was elicited; and that he had a prevailing sense of hopelessness and helplessness. It was noted that the veteran could recall six digits forward and four digits backward, that his abstract thinking showed some concreteness, that he could subtract 33 cents from a dollar, that no signs of schizophrenia were elicited, that his fund of knowledge was poor, and that he appeared to be in the borderline to dull normal range clinically which affected his anxiety to some extent. The examiner noted that the veteran had no suicidal or homicidal ideation and that his insight into his problems appeared to be fair. It was noted that the veteran lived with his wife and that their relationship was well," that he had no particular hobbies, that he had a long history of psychiatric impairment, that he attended church regularly, that he was currently being treated at the mental hygiene clinic, and that he was able to take care of his personal chores and hygiene. The veteran reported that he did not belong to any clubs or organizations. The relevant diagnosis was generalized anxiety disorder, recurrent, mild to moderately severe in nature; and adjustment disorder with anxious and depressed mood secondary to physical illness and situational factors. At the June 1996 Travel Board hearing, the veteran testified that he was taking medication for his nerves, such as Valium, Trazodone, and diazepam; that he received mental health treatment at the VA hospital every three months; that he was last treated earlier that week; and that he became nervous, aggravated, and angry particularly when his physical disabilities prevented him from doing things that he wanted to do. Tr. at 12-16. He reported that he lived with his wife, that they socialized as much as they could, that they sometimes ate out, that he knew his neighbors, and that he attended church every Sunday. Tr. at 16, 17. He also stated that he did not like crowds, that he tried to get out of church as quickly as he could, and that he liked to socialize with people as long as they didn't start an argument "or something." Id. A June 1996 VA outpatient treatment record reveals that the veteran was having a hard time adjusting to various psychosocial pressures, that he was getting depressed and having a hard time coping, and that he reported that he was nervous, irritable, and depressed. The veteran also stated that his medications helped but that he had no pep or energy. He stated that he was "doing fair." The examiner noted that the veteran had no suicidal or homicidal ideation. The examiner started the veteran on Prozac and instructed the veteran to keep himself as active as possible psychosocially. The relevant diagnosis included major affective disorder, recurrent, moderate to moderately severe in nature; generalized anxiety disorder; adjustment disorder with anxious and depressed mood secondary to physical and situational factors (he has myasthenia gravis). An October 1996 VA outpatient treatment record shows that the veteran was taking Prozac, Valium, and Trazodone. The veteran complained of lack of energy and stated that he was doing fair otherwise. It was noted that the veteran had no homicidal or suicidal ideation. The examiner recommended that the veteran increase his dose of Prozac and it was noted that the Trazodone helped him sleep. The examiner advised the veteran to increase his physical and social activities. The pertinent diagnosis was major affective disorder, recurrent, moderate to moderately severe in nature and adjustment disorder with anxious and depressed mood, secondary to physical illness and situational factors. At the January 1997 VA psychiatric examination, the veteran reported that he had been significantly nervous, anxious, and edgy. He stated that he felt like he was getting progressively worse, that he got panicky and shaky, and that he was concerned about his medical problems. He reported that he was frustrated because he was not able to do what he used to do, that he felt very irritated, and that he could not get along with people. The veteran stated that he had been having nightmares, that he woke up from violent dreams, that he could not sleep well unless he took his medication, that he had been feeling depressed, that he had some hopeless and helpless feelings, that he felt tired and run down, and that he was easily irritated and frustrated. He reported that he had had a nervous breakdown in 1989 and was admitted to the Beckley, West Virginia VA hospital for three months. He stated that he had had suicidal and homicidal thoughts in the past but that he was not currently suicidal or homicidal. The veteran reported that he felt guilty about losing patience and raising his voice with his family and other people. He stated that he felt like he had no patience with anything, that he got upset easily, and that it was hard for him to be around people. The January 1997 VA examiner noted that the veteran had a son and two daughters; that he was casually dressed and appropriately groomed; that he was rather tense, anxious, edgy, depressed, and withdrawn; that he was oriented for person, place, and time; that there was no evidence of any active hallucinations or delusions; that attention and concentration was impaired; and that he had difficulty with mental calculations and serial sevens. The veteran was able to give the days of the week in reverse order, his memory and recall for recent events was slightly impaired, he was able to recall one out of three objects after five minutes, and there was no evidence of any looseness of association, flight of ideation, or pressured speech. The examiner noted that the veteran's fund of knowledge was appropriate for his education level and background. The relevant impression was generalized anxiety disorder and dysthymic disorder. The examiner noted that the severity of the psychosocial stressors appeared to be moderate and that the current highest level of adaptive functioning appeared to be 60 on the global assessment of functioning (GAF) scale. The examiner further commented that he felt that the veteran had problems with chronic recurrent anxiety and depression, that his physical problems contributed to his nervousness and depression, and that a combination of his physical and psychiatric impairment made him disabled from being gainfully employed. Pertinent Law and Regulations Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. 1155; 38 C.F.R. Part 4 (1996). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. 1155; 38 C.F.R. 4.1, 4.10 (1996). Separate diagnostic codes identify the various disabilities. In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include 38 C.F.R. 4.1, 4.2 (1996), which require the evaluation of the complete medical history of the claimant's condition. These regulations operate to protect claimants against adverse decisions based on a single, incomplete, or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet. App. at 593-94. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, See 38 C.F.R. 4.2, 4.41 (1996), the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). With respect to psychiatric disability, before November 7, 1996, VA regulations provided that the severity of a psychiatric disorder was premised upon actual symptomatology, as it affected social and industrial adaptability. 38 C.F.R. 4.130 (1996). Two of the most important determinants were time lost from gainful employment and decrease in work efficiency. Id. The pre-November 7, 1996, schedular criteria provide a 10 percent evaluation for generalized anxiety disorder where there is less than the criteria for the 30 percent rating, with emotional tension or other evidence of anxiety productive of mild social and industrial impairment. 38 C.F.R. 4.132, Part 4, Diagnostic Code 9400 (1996). Generalized anxiety disorder warrants a 30 percent evaluation where there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people and the psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. 38 C.F.R. 4.132, Part 4, Diagnostic Code 9400 (1996). Definite impairment has been construed to mean "distinct, unambiguous, and moderately large in degree." VAOPGCPREC 9-93 (November 9, 1993). A 50 percent evaluation for generalized anxiety disorder is warranted where the ability to establish or maintain effective or favorable relationships with people is considerably impaired and by reason of the psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. 38 C.F.R. 4.132, Diagnostic Code 9400. Considerable impairment has been construed to mean "rather large in extent or degree." See VAOPGCPREC 9-93 (November 9, 1993). 38 C.F.R. 4.132, the VA Schedule of Ratings for Mental Disorders, was amended and redesignated as 38 C.F.R. 4.130, effective November 7, 1996. Under the new regulation, the evaluation criteria have substantially changed, focusing on the individual symptoms as manifested throughout the record, rather than on medical opinions characterizing overall social and industrial impairment as mild, definite, considerable, severe, or total. Effective November 7, 1996, 38 C.F.R. 4.130, provides a 10 percent evaluation when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent disability rating is warranted for generalized anxiety disorder when there is 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted for 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 or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 61 Fed. Reg. 52695-52702 (October 8, 1996) (codified at 38 C.F.R. 4.130). Consistent with the decision of the Court's decision in Karnas v. Derwinski, 1 Vet. App. 308 (1991), the Board will discuss the veteran's disability with consideration of the criteria effective both prior and subsequent to November 7, 1996. Analysis Based on the evidence of record in conjunction with the schedular criteria in effect prior to November 7, 1996, under 38 C.F.R. 4.132, Diagnostic Code 9400, and the new criteria effective November 7, 1996, the Board concludes that a separate 30 percent evaluation is warranted for the veteran's service-connected generalized anxiety disorder. The Board notes that there have been additional psychiatric diagnoses including PTSD, acute hysterical reactions, hysteria, passive personality disorder, adjustment disorder with anxious and depressed mood secondary to physical illness and situational factors, major affective disorder, and dysthymic disorder, all of which are not currently service connected. The veteran was also diagnosed with transient psychosis associated with hypertension on one occasion in 1989. Although it is unclear exactly which of his psychiatric symptoms are attributable to the service-connected generalized anxiety disorder and which are attributable to the additional psychiatric disorders, the Board finds that the veteran's total psychiatric disability picture meets but does not exceed the criteria for a 30 percent rating. The evidence shows that the veteran has consistently complained of symptomatology that primarily includes anxiety, nervousness, frustration, irritability, shakiness, tension, anger, edginess, nervous energy with sweating, speaking loudly, hyperactivity, insomnia, social isolation, depression, nightmares, startle response, intrusive thoughts, and flashbacks. The veteran also reported that he was a perfectionist and got nervous when things did not go his way. The record reflects that the veteran worked for the VA as a radiology technologist from 1953 to 1974, and that he had also worked as an elevator operator and janitor. In 1974 he was placed on disability retirement due to progressive muscle weakness due to myasthenia gravis and back strain. Therefore, the veteran has not worked in more than 20 years due to physical disability. In addition, the veteran has been married to his current wife for approximately 44 years and he has 3 grown children. At the May 1991 VA examination, he reported that his relationship with his wife was fair and, at the March 1996 VA examination he stated that his relationship with his wife was "well." At the March 1993 VA psychiatric examination, the veteran reported that working had helped him because it took his mind off of several things and that since he had retired he had had more problems with his nerves. At the June 1996 Travel Board hearing, he reported that he lived with his wife, that they socialized as much as they could, that they sometimes ate out, that he knew his neighbors, and that he attended church every Sunday. Tr. at 16, 17. He also stated that he did not like crowds, that he tried to get out of church as quickly as he could, and that he liked to socialize with people as long as they don't start an argument "or something." Id. At the January 1997 VA examination, the veteran reported that he could not get along with people, that he felt guilty about losing patience and raising his voice with his family and other people, that he felt like he had no patience with anything, that he got upset easily, and that it was hard for him to be around people. The veteran also reported that he had no hobbies and that he did not belong to any clubs or organizations. Regarding the criteria effective November 7, 1996, a 10 percent evaluation is warranted where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or; symptoms controlled by continuous medication. A 30 percent evaluation requires occupational and social impairment manifested by an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks with satisfactory general functioning such as the ability to continue in routine behavior, self-care, and normal conversation. Such includes recognition of a depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation requires 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 or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 61 Fed. Reg. 52695-52702 (October 8, 1996) (codified at 38 C.F.R. 4.130). The Board finds that a 30 percent evaluation is warranted under the revised rating criteria because there is evidence of depressed mood, anxiety, rare panic attacks, chronic sleep impairment, and mild memory loss. However, the veteran's generalized anxiety disorder symptoms are not of such a severity as to cause occupational and social impairment with reduced reliability and productivity; the medical evidence is negative for indications of flattened affect; panic attacks more than once a week; difficulty in understanding complex commands; and disturbances of motivation and mood. Although the March 1993 VA psychiatric examiner noted that the veteran had rather rambling speech, was circumstantial, and had difficulty organizing his thinking, the record contains no other evidence of circumstantial, circumlocutory, or stereotyped speech. In fact, the September 1989, May 1991, March 1996, and January 1997 examiners noted that the veteran spoke quite well; that there was a logical progression in the association of ideas; that speech was clear, rational, appropriate, and audible; and that there was no evidence of looseness of association, flight of ideation, or pressured speech. Even though the March 1993 and January 1997 VA examiners noted that the veteran's memory and recall for recent events was slightly impaired, the Board notes that the criteria for a 30 percent evaluation include mild memory loss. The May 1991 VA examiner noted that the veteran's abstract thinking was poor and the March 1996 VA examiner noted that his abstract thinking showed some concreteness. However, the May 1991 VA examiner also noted that his insight, judgment, and problem solving seemed fair; the March 1993 examiner noted that the veteran's attention and concentration were normal; and the March 1996 VA examiner reported that there was no evidence of a thought disorder and that his insight into his problems was fair. It is noted that poor abstract thinking, absent the other criteria for a 50 percent evaluation, is not sufficient to warrant a 50 percent evaluation. The most recent VA examination, conducted in January 1997, revealed that the veteran was oriented for person, place, and time; that there was no evidence of active hallucinations or delusions; that his attention and concentration were impaired; that his memory and recall for recent events were slightly impaired; that there was no evidence of any looseness of association, flight of ideation, or pressured speech; and that fund of knowledge was appropriate for his education level and background. The Board notes that a 30 percent evaluation contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupations tasks due to such symptoms such as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment and mild memory loss. The Board finds that a 30 percent evaluation most appropriately reflects that veteran's disability due to generalized anxiety disorder. With respect to the pre-November 7, 1996, schedular criteria for generalized anxiety disorder, a 30 percent evaluation is warranted where there is definite impairment in the ability to establish or maintain effective or wholesome relationships with people and the psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. As noted above, definite impairment has been construed to mean "distinct, unambiguous, and moderately large in degree, more than moderate but less than rather large." VAOPGCPREC 9-93 (November 9, 1993). The veteran is shown to have such impairment. In that regard, the May 1991 VA examiner diagnosed chronic generalized anxiety disorder, recurrent, moderate to moderately severe, and the March 1996 VA examiner diagnosed generalized anxiety disorder, recurrent, mild to moderately severe in nature. The January 1997 VA examiner also assigned a GAF score of 60. The Court has held that global assessment of functioning (GAF) scores between 55 and 60 indicate only "moderate difficulty in social, occupational, or school functioning." See Carpenter v. Brown, 8 Vet. App. 243 (1995). Therefore, the January 1997 GAF of 60 does not indicate more than moderate impairment of occupational and social functioning. Additionally, the veteran's lack of social life is significant only for any impact such has on his occupational functioning. 38 C.F.R. 4.129, 4.130. In any event the veteran is shown to have social contacts based on his report of attending church every Sunday; trying, along with his wife, to socialize as much as possible; eating out; knowing his neighbors; and enjoying socializing with people as long as they didn't start an argument. Based on the manifestations of the veteran's anxiety disorder and his current GAF score, it is concluded that the anxiety disorder does not result in more than definite (rather large) social and industrial impairment and does not warrant assignment of a 50 percent evaluation. In that regard, the record fails to establish that the veteran's ability to foster or maintain effective or favorable relationships with people is considerably impaired or that by reason of psychoneurotic symptoms, his reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment to warrant the assignment of a 50 percent evaluation. 38 C.F.R. 4.132, Diagnostic Code 9400. Thus, the evidence pertaining to the veteran's anxiety disorder is consistent with a 30 percent rating under the old and new rating criteria, and it is preponderantly against the assignment of an evaluation in excess of 30 percent. The evidence is not in relative equipoise nor does the disability picture, as discussed above, more nearly approximate the criteria for a higher rating. Accordingly, the provisions of 38 U.S.C.A. 5107(b) and 38 C.F.R. 4.3, 4.7 (1996) are not for application. ORDER Entitlement to a separate 30 percent evaluation for generalized anxiety disorder is granted, subject to regulations that control monetary payments. REMAND The veteran essentially contends that his service-connected duodenal ulcer disease with colitis is more disabling than the current 40 percent evaluation reflects. He asserts that his duodenal ulcer disease has increased in severity; that he has incapacitating episodes two to three times a year which each last at least 60 days; and that these episodes include dark stools, blood in his stool, epigastric pain, nausea without actual vomiting, tarry stools, a great deal of gas, feeling bloated after meals, and burping up his food. He reports that his ulcers are painful, that he has reflux and heartburn quite often, that he takes medications twice daily, and that he is sometimes confined to bed rest due to his ulcer condition. In a March 1996 treatment record, Dr. Salon noted that the veteran reported that the he had had dark stools in February 1996 and that he went to the VA hospital for treatment. The Board notes that there are no February 1996 VA treatment records in the claims file, and it appears that there may other pertinent records that have not yet been obtained. At the June 1996 Travel Board hearing, the veteran reported that he had been treated at the VAMC for a bleeding ulcer and blood in his stool in December 1995 and that this episode lasted until March 1996. Tr. at 10, 18, 19. The March 1996 VA examiner noted that the veteran had had a recent bleeding ulcer in December 1995 and recent helicobacter (H.) pylori. The Board notes that the claims file includes a December 1995 upper gastrointestinal report; however, the December 1995 treatment records have not been obtained. In a February 1997 VA outpatient treatment record, the examiner noted that the veteran had been treated on October 10, 1996, and that the diagnosis had included severe gastroesophageal reflux disorder, remote severe duodenal ulcer, and hypertrophic gastritis. The examiner also noted that the veteran had been treated in January 1997 and that he had complained of rectal bleeding. The October 1996 and January 1997 treatment records have not been obtained. Although the RO did obtain medical records from the Beckley, West Virginia VAMC dated from June 1996 to early December 1996 pursuant to the November 1996 remand instructions, the Board finds that an attempt to obtain all pertinent records from the Beckley, West Virginia VAMC from 1993 to present, to include the December 1995, February and October 1996, and January 1997 treatment records and all reports of hospitalization, is warranted. In a February 1997 private treatment record, Z. Resheed, M.D., noted that the veteran had melena looking stool, some weight loss, abdominal pain, and history of peptic ulcer disease. The veteran underwent an esophagogastroduodenoscopy which revealed esophagitis, erythema of the mucosa, a small hiatus hernia, severe gastritis in the body of the stomach with abnormal looking folds, mild gastritis in the antrum, a somewhat deformed antrum probably from previous peptic ulcer disease, and duodenitis with deformity of the duodenum probably secondary to past peptic ulcer disease. Several biopsies were taken. The pathology report diagnosis was biopsies from stomach showing chronic gastritis and biopsy from esophagus showing chronic esophagitis. At the May 1997 VA examination of the intestines and alimentary appendages, the veteran complained of chronic constipation which he thought was secondary to his medications. He denied diarrhea with mucus or blood. The examiner noted that the veteran weighed 180.5 pounds and that his maximum weight in the last year had been 210 pounds; that he did not have anemia, anorexia, malnutrition, nausea, or vomiting; that he had food intolerance of hard meat; that he had moderate pain and generalized weakness; that he had constipation and no recent attacks of colitis; that there was no abdominal disturbance; and that there was no active rectal bleeding. The diagnosis included duodenal ulcer, chronic hypertrophic gastritis, esophagitis, and gastroesophageal reflux disorder. The Board notes that it is not clear whether the May 1997 VA examiner had the opportunity to review the claims file; in any event, there are some additional matters that must be addressed by an examiner. In addition, as noted above, it appears that there are additional recent VA treatment records which have not yet been obtained. In order to ensure that the record is fully developed, this case is REMANDED to the RO for the following: 1. The RO should contact the veteran and request that he provide the names and addresses of any physicians and facilities from which he obtained treatment for his duodenal ulcer disease and colitis since 1993. After obtaining appropriate authorization, the RO should attempt to obtain records from the sources indicated, to include the December 1995, February and October 1996, and January 1997 treatment records and all reports of hospitalization from the Beckley, West Virginia VAMC; all pertinent treatment records from the Richmond, Virginia VAMC; and all pertinent records from the Beckley Hospital. Any records obtained should be associated with the claims file. 2. After the aforementioned development has been completed to the extent possible, the veteran should be afforded a comprehensive VA gastrointestinal examination, to determine the current manifestations and severity of his service-connected duodenal ulcer disease with colitis. The veteran's claims folder and a separate copy of this remand should be made available to the examiner, the receipt of which should be acknowledged in the examination report. Any indicated studies, including gastrointestinal series, should be performed. The veteran's history, current complaints, and examination findings must be reported in detail by the examiner. The examiner should identify all gastrointestinal disorders found and note the frequency, severity, and duration of manifestations. Additionally, the examiner should express an opinion as to whether any hiatal hernia, gastritis, esophagitis, gastroesophageal reflux or other nonservice-connected gastrointestinal disorder, if found, is as likely as not related by causation or aggravation, to the service-connected ulcer disease or colitis. The examiner should specifically state whether the veteran has ulcerative colitis and if so whether it is productive of malnutrition, anemia, general debility, or serious complications such as liver abscess. The examiner also is asked to each of the following: Does the veteran have (1) pain only partially relieved by standard ulcer therapy; (2) periodic vomiting; (3) recurrent hematemesis or melena; (4) anemia; (5) weight loss; (6) incapacitating episodes, their frequency per year and their duration; (6) episodes of severe symptoms, their frequency per year and their duration (7) continuous moderate manifestations. All findings should be reported in detail, a complete rationale must be given for any opinion expressed, and the foundation for all conclusions should be clearly set forth. A comprehensive report which addresses the aforementioned, should be provided and associated with the claims folder. 3. The RO should then review the record. If the examination report is not responsive to the Board's instructions, it must be returned to the examiner as inadequate. 4. The claim should then be readjudicated with consideration of all pertinent law, regulations, and Court decisions, to include 38 C.F.R. 4.114, Diagnostic Codes 7305, 7319, 7323 (1996). If the veteran's claim remains denied, he and his representative should be provided with a supplemental statement of the case, which includes all pertinent law and regulations and a full discussion of action taken on the veteran's claim. consistent with the Court's instructions in Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The applicable response time should be allowed. This case should then be returned to the Board, if in order, after compliance with the customary appellate procedures. No action is required of the veteran until he is so informed. The Board intimates no opinion as to the ultimate decision warranted in this case, pending completion of the requested development. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Boar or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. 5101 (West Supp. 1997) (Historical and Statutory Notes). In addition, VBA's ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. JANE E. SHARP Member, Board of Veterans' Appeals Under 38 U.S.C.A. 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. 20.1100(b) (1996).