Citation Nr: 0002420 Decision Date: 01/31/00 Archive Date: 02/02/00 DOCKET NO. 98-09 997A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated at 50 percent disabling. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Edward Walls, Associate Counsel INTRODUCTION The veteran served on active duty from December 1952 to September 1954. His appeal comes before the Board of Veterans' Appeals (Board) from an April 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The veteran testified before the Travel Board in a November 1999 hearing. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. The veteran's PTSD causes total occupational and social impairment. CONCLUSION OF LAW The criteria for an evaluation of 100 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran contends that he is more disabled than his 50 percent evaluation suggests. Rather, his PTSD symptomatology has worsened since his retirement and he is suffering from severe symptomatology as the result of his combat during the Korean War. The Board recognizes the veteran's contention; however, the preliminary issue is whether he has submitted a well-grounded claim, and if so, whether the VA has properly assisted him in the development of the claim. Considering the veteran's contention, the Board finds his claim plausible and capable of substantiation and therefore well grounded within the meaning of 38 C.F.R. § 5107(a) (West 1991). See Caffrey v. Brown, 6 Vet.App. 337, 381 (1994); Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992). The Board is also satisfied that the RO has developed all relevant evidence necessary for an equitable disposition of this appeal; thus, no further assistance to the veteran is required. In accordance with 38 C.F.R. §§ 4.1, 4.2 (1999) and Schafrath v. Derwinski, 1 Vet.App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's service-connected disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. The Board concludes that this case presents no evidentiary considerations, except as noted below, which warrant an exposition of the remote clinical history and findings pertaining to the disability at issue. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Although regulations require that a disability be viewed in relation to its whole recorded history, see 38 C.F.R. §§ 4.1, 4.2, 4.41, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The RO service connected the veteran's PTSD in June 1995, and he is currently evaluated at 50 percent disabled under DC 9411. That code provides a 50 percent disability evaluation for PTSD causing occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability evaluation is warranted for PTSD causing occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or the inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for PTSD causing total occupational and social impairment, 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; or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). In this case, an August 1994 letter from Margaret A. MacDevitt, Ph.D., reflects that she had been treating the veteran for PTSD since October 1993 after the veteran had been arrested for shoplifting. During her psychotherapy sessions with the veteran, he had expressed a great deal of anger toward "the establishment" as a result of his disillusionment from the Korean War. Following his service, the veteran showed intense psychological distress when exposed to news coverage of wars in general. He had recurrent and intrusive distressing recollections of the war, and he attempted to avoid situations and conversations that aroused memories of his experience. He complained of irritability, hypervigilance and compulsive behavior. The psychologist reported that the veteran's PTSD symptoms had increased following his retirement. During a March 1995 VA examination, the veteran reported that only 20 soldiers were left of his original unit at the time the unit was removed from combat due to its loss of combat effectiveness. The other soldiers had either been killed or wounded. He said he was exposed to numerous traumatic events, that he witnessed many of his friends being killed or wounded during trench warfare, and that he had been awarded the Combat Infantry Badge. His military separation report reflects that he received that award, which indicates that the veteran is a combat veteran. He also reported that he had flashbacks, nightmares, and intrusive thoughts. He told the examiner that encounters with Asians had produced flashbacks and crying spells, and that he felt intense survivor guilt. On mental status examination, the veteran was noted to have irritability, difficulty concentrating, hypervigilance, and an exaggerated startle response. The examiner diagnosed chronic PTSD with delayed onset, and he reported that the veteran's Global Assessment of Functioning (GAF) score was 65. During a VA mental disorders examination in December 1997, the veteran stated that the reason he worked so intensively during his employment was to cope with his mental difficulties. Thus, his retirement had produced a worsening of his PTSD symptomatology. He complained of increased nightmares, from one or two times a month as of two years ago to five or six nightmares a week at the time of the December 1997 examination. He continued to have several intrusive thoughts a day, especially around the anniversaries of the date on which he was drafted and the dates of significant battles. He reported experiencing frequent flashbacks, which were triggered by clicking noises, the smell of charcoal, and firecrackers. He had become extremely nervous around crowds. He slept poorly, and awakened at night to patrol his home with a gun. He was hypervigilant, easily startled, and he had depression and numbness. The examiner stated that the veteran's social judgment and insight appeared somewhat marginal, and that the veteran had anxiety, poor impulse control, a low frustration tolerance, and difficulty managing anger and relating to others. The examiner assessed the veteran's GAF score at 50. Outpatient treatment records dated February 1997 to November 1998 show that the veteran was undergoing weekly therapy during that time. However, the notes are not probative because they are not specific to this particular veteran. However, a December 1998 letter from a group therapist directly concerns the veteran. The letter reflects that the veteran had made limited progress in recovery during his weekly therapy groups. However, the symptoms of hypervigilance, exaggerated startle response, sleep difficulty, intrusive thoughts, survivor guilt, avoidance thoughts and restricted range of emotions remained. The group therapist indicated that the veteran was "clearly disabled" as the result of his PTSD. During an examination in June 1998, the veteran reported that he felt extremely guilty that he could not better protect the soldiers he had been assigned to orient to battlefield conditions during the war. Anthony Holzgang, M.D., the examining physician, noted that the veteran broke down into sobs when relating this information. The veteran said that he had nightmares of wounded soldiers at aide stations. His affect was quite labile with the veteran going from tears to essentially euthymic states very rapidly. Dr. Holzgang indicated that although the veteran had been able to maintain a long-term relationship with his wife, he suffered from PTSD due to combat. The veteran testified in December 1998 at an RO hearing that he checks his house at night with a gun; apparently he thought of his family room as his bunker and the rest of the house as his perimeter. He stated that he did not like to travel because it reminded him of his travel to Korea on a boat and train. He liked cloudy days better than clear days because the Chinese would attack on clear days. He also indicated that his shoplifting had caused much shame to his family. During a November 1999 Travel Board hearing, the veteran reported much of the same symptomatology. He said that the smell of coal caused him to have flashbacks because there was the smell of coal on the battlefield. The veteran clarified that he was, in fact, taking medication. The veteran's representative stated that this case was unusual because of the veteran's shoplifting. His shoplifting showed that the veteran was irrational at times; thus, he should be evaluated at 100 percent disabled. The record clearly shows that the veteran is suffering from numerous PTSD symptoms, including intrusive thoughts, nightmares, flashbacks, hypervigilance, and exaggerated startle response. Moreover, the veteran's PTSD may be manifesting itself through his shoplifting. The veteran was able to maintain his employment for more than 35 years, but this may be due to an avoidance of thoughts of the Korean War. The veteran's group therapist indicated that the veteran was "clearly disabled." As stated above, the veteran's GAF score was 50 in December 1997. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV), a GAF score of 41 to 50 reflects serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). Although the veteran has maintained his marriage and his employment, the record shows that the veteran's PTSD currently causes total occupational and social impairment based on this medical evidence and his most recent GAF score. There are several diagnoses of PTSD with delayed onset. Thus, the Board concludes that he meets the criteria for a 100 percent evaluation. ORDER Subject to the regulations governing the payment of monetary benefits, entitlement to a 100 percent evaluation for PTSD is granted. WARREN W. RICE, JR. Member, Board of Veterans' Appeals