Citation Nr: 0004499 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 93-13 074 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York THE ISSUE Entitlement to an increase in a 50 percent rating for a psychiatric disorder with sinus tachycardia. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R. T. Jones, Counsel INTRODUCTION The veteran served on active duty from June 1942 to October 1945. This case initially came to the Board of Veterans' Appeals (Board) from a January 1993 RO decision which denied an increase in a 50 percent rating for a psychiatric disorder with sinus tachycardia. The psychiatric disorder has been variously classified as post-traumatic stress disorder (PTSD) and an anxiety reaction. The case was remanded by the Board in March 1995 and July 1999, and it was last returned to the Board in November 1999. During the course of the current appeal, the veteran raised claims for service connection for a number of other medical conditions. As pointed out in the July 1999 Board remand, the veteran withdraw such claims in writing in September 1998, and the only issue certified for appellate review is an increased rating for the psychiatric disorder with sinus tachycardia. The veteran has continued to make contentions evidencing a belief that he is service connected for organic heart disease; e.g., supraventricular arrhythmias and atrial fibrillation. The Board has denied service connection for organic heart disease in 1972 and 1989, and the veteran is not now service-connected for any organic heart disease. The veteran may file to reopen a claim for service connection for organic heart disease by submitting new and material evidence to the RO. FINDING OF FACT The veteran's service-connected psychiatric disorder (variously diagnosed as PTSD and an anxiety reaction, with sinus tachycardia) is productive of total occupational and social impairment. CONCLUSION OF LAW The criteria for a 100 percent rating for a service-connected psychiatric disorder have been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.132, Diagnostic Code 9400, 9411 (1996), 38 C.F.R. § 4.130, Diagnostic Code 9400, 9411 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION I Background The veteran served on active duty in the Army from June 1942 to October 1945. Service medical records note treatment for nervousness with tachycardia. Service personnel records show the veteran performed duties of a medical-surgical technician, including treating battle casualties with a rifle platoon in Europe during World War II. He was wounded in combat and received the Purple Heart. Besides his service- connected psychiatric disorder, he is service-connected of residuals of a left hand wound (which is rated noncompensable). In an October 1946 decision, the RO granted service connection for psychoneurosis anxiety and tachycardia, each rated 10 percent effective from his separation from service. In 1951 his rating for psychoneurosis anxiety was reduced to 0 percent, and in 1955 his anxiety and tachycardia were combined into one disability which was rated 10 percent. In December 1972 the Board denied service connection for organic heart disease after obtaining the opinion of an independent medical expert. The Board specifically pointed out that the veteran's service-connected sinus tachycardia was quite different from non-service-connected ventricular tachycardia. The rating for anxiety reaction with tachycardia was increased to 30 percent in a 1974 RO decision, and the rating was increased to 50 percent in a 1976 RO decision. The 50 percent rating has been continuously in effect ever since. Historical medical records from the 1970s and 1980s note the service-connected psychiatric disorder, as well as non- service-connected physical ailments such as organic heart disease (with myocardial infarctions). The records show the veteran has a college degree and worked as a state counselor for 36 years before retiring at the end of 1981 at age 63. In September 1989 the Board again denied service connection for organic heart disease. The veteran filed for an increased rating for his service- connected psychiatric disorder in June 1992. In an August 1992 VA psychiatric examination, the veteran described flashbacks and nightmares of his experiences in combat during World War II. (Similar flashbacks, nightmares, and recollections were described on all other subsequent VA examinations. He also gave the examiner a typed list of combat memories and claimed war injuries) He reported he had had to accept an early retirement from his job with the New York Department of Labor. The examiner said the veteran presented a long history of PTSD, which is kept under control at his late age with mild tranquilizers, but that the PTSD was not totally under control. The diagnosis was PTSD, moderately severe to severe. VA outpatient treatment records from 1993 to 1995 show treatment primarily for heart disease and hypertension. It was noted that that he had a history of coronary artery disease with myocardial infarctions in 1971 and 1985. In June 1995 the veteran submitted a January 1990 statement from A. Singh, M.D., regarding the relationship between stress and heart disease. On a December 1995 VA psychiatric examination, it was noted that the veteran was under treatment at a VA outpatient clinic and was taking numerous medications, primarily for cardiovascular disease. Mental status examination showed he was profoundly depressed, anxious, and agitated during the examination. He was not hallucinated, delusional, or psychotic. His mood and affect were both depressed, and he manifested a general form of anxiety that seemed to reach semi-panic proportions during the examination itself. He admitted to suicidal ideation, but denied suicidal intent. Recent and remote memory were only grossly intact, and recent memory was grossly impaired by depression and lack of concentration ability. Insight was superficial, and judgment was fair. The examiner said the veteran presented signs and symptoms of severe PTSD, and took 3 times the medications that he took 2 years ago for tachycardia and other manifestations of his anxiety reaction. The examiner said the veteran was unemployable due to the severity of his condition and was isolated and consumed with the tachycardia and feelings of panic attack. The diagnosis was severe PTSD. His GAF level was reported to be 34. In a claim for a total compensation rating based on individual unemployability received in December 1996, the veteran reported that he had a college degree and worked from 1945 to January 1982 (age 63) as a state counselor for New York state, when he retired because of psychiatric symptoms. He claimed he became too disabled to work in January 1986 (he was hospitalized for a myocardial infarction from December 1985 to January 1986) and he said the service-connected disability which prevented work was PTSD with tachycardia and heart disease. [As noted, the veteran is not service connected for organic heart disease.] On a December 1996 VA psychiatric examination, the veteran reported that he had been unable to drive a car since his discharge from service because of his anxiety. He said his activity was limited to watching television, reading, and doing things around the house. Mental status examination revealed a 78 years old man who looked older than his stated age. He was anxious throughout the interview. He blamed all his problems on his tachycardia, which he said led to his heart attacks and other problems. His mood was slightly depressed, and his affect was mood congruent. There was no evidence of a thought disorder. His memory was intact. There was no evidence of organicity. All his thoughts centered on his difficulties since being discharged from service. The diagnosis was chronic anxiety disorder. His GAF score was listed as 50 to 58. On a September 1997 VA psychological evaluation, it was reported that the veteran had been on diazepam for an unspecified number of years. The veteran reported he was unable to drive a car because of panic and confusion and that his 36 year career as a New York state employee had been adversely affected by his inability to drive. He said he was somewhat depressed and felt guilty about his current condition and his experiences during World War II. He was oriented times 3. He had a good fund of knowledge and answered questions logically and sequentially. No evidence of confusion was noted. He was a good historian who showed no memory deficits. His affect was neither flattened nor blunted. He complained of depression, but none was noted on the interview. He was anxious during the interview, and all mood was congruent. His anxiety was somewhat pervasive and he said that it disrupted his entire life. No evidence of a thought disorder was seen. The examiner said that the veteran evidenced a chronic anxiety disorder that was unchanged since the December 1996 VA compensation examination. The diagnosis was chronic anxiety disorder, and the examiner assigned a GAF score of 58. In September 1997 a VA medical doctor said the veteran reported tachycardia twice a week and that the veteran had angina that was precipitated by tachycardia caused by anxiety. In a December 1998 psychological evaluation received from TARA (Trauma and Addictions Recovery Associates), the examiner reported that the veteran suffered from intrusive memories of traumatic incidents and symptoms of anxiety since his return from World War II. He reported sleep disturbance, frequent regurgitation and loss of appetite, flashbacks, nightmares, irritability, and attacks of guilt. He reported he had severe panic attacks several times a week that made it impossible for him to drive. It was reported that his symptoms had worsened since his retirement. It was noted that his prior job involved counseling veterans. The examiner's assessment was PTSD, and a GAF score of 40 was assigned. On a February 1999 VA psychiatric evaluation for PTSD, the VA psychologist reviewed the veteran's claims folder and reports of previous examinations. It was reported that the veteran was getting anti-depressants for dysthymia from the VA, and had had 8 sessions from a private therapist since the fall of 1998. It was reported that the diagnosis from that facility had been PTSD, and he had been assigned a GAF score 41. It was reported that the veteran got along well with his wife of 53 years and got along well with his 2 daughters. It was noted that he had worked for 36 years as a New York State veteran's counselor until he retired in 1981 when he was 62 years old. It was noted that had good activities of daily living and hygiene. He was anxious throughout the interview with a somewhat pressurized speech. He did not relax throughout the interview. He complained frequently, and his affect was congruent with his mood. His recent and remote memory was intact. There was no evidence of a thought disorder, and he was oriented to time, place, and person. He obsessed about World War II incidents, but put little effort into stopping these memories. He reported he had diminished interest in significant activities. He said he felt estranged from people and unable to enjoy almost anything in life. He reported difficulty sleeping. He was irritable, had some difficulty concentrating, and had an exaggerated startle response. The psychiatric diagnoses were PTSD, chronic with moderate symptoms; dysthymia secondary to PTSD; and anxiety disorder. The examiner said the GAF score was 52 for all psychiatric disorders. In July 1999 the veteran was seen at a VA geriatric primary care clinic where he reported that he had up to 3 attacks of angina and palpations a week. He reported that the attacks would come at various times a day including early in the morning when he was in bed. The veteran said he would develop chest pain 2-3 minutes into the attack that was generally relieved by a single nitroglycerin tablet. It was reported that the attacks lasted 20-30 minutes. The impression was that he had paroxysmal supraventricular tachycardia, which induced angina. The doctor added that the veteran was service connected for anxiety neurosis or PTSD, atrial fibrillation, and sinus tachycardia, and that he had a number of other active medical problems, including ischemic heart disease with angina pectoris, palpitations and tachycardia, diabetes mellitus, depression, and insomnia. The doctor opined that the veteran was unemployable and totally disabled due to his service-connected disabilities. II. Analysis The veteran's claim for an increase in a 50 percent rating for his service-connected psychiatric disorder (variously diagnosed as PTSD and an anxiety reaction, with sinus tachycardia) is well grounded, meaning plausible. The RO has properly developed the evidence, and there is no further VA duty to assist the veteran with his claim. 38 U.S.C.A. § 5107(a). When rating the veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, it is the more recent evidence which is generally the most relevant to an increased rating claim, as the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. During the course of the veteran's appeal, the regulations pertaining to psychiatric disabilities were revised. The service-connected psychiatric disorder was initially evaluated under 38 C.F.R. § 4.132, Code 9400 (anxiety disorder) or 9411 (PTSD), as in effect prior to November 7, 1996. The old rating criteria provide that a 50 percent rating is assigned when the ability to maintain effective or favorable relationships with people is considerably impaired, and by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent rating is assigned when the ability to established and maintain effective or favorable relationships with people is severely impaired, and the psychoneurotic symptoms are of such severity that there is severe impairment in the ability to obtain or retain employment. A 100 percent rating is assigned when the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community; totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior; demonstrably unable to obtain or retain employment. On November 7, 1996, the rating criteria for psychiatric disorders were revised and are now found in 38 C.F.R. § 4.130, Code 9400 (anxiety disorder) or 9411 (PTSD). The new rating criteria provide that a 50 percent rating is to be assigned 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; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is to be assigned for 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); inability to establish and maintain effective relationships. A 100 percent rating is assigned for 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; memory loss for names of close relatives, own occupation, or own name. As the veteran's claim for an increased rating for the service-connected psychiatric disorder was pending when the regulations pertaining to psychiatric disabilities were revised, he is entitled to the version of the law most favorable to him. Karnas v. Derwinski, 1 Vet. App. 308 (1990). Here, either the amended or current rating criteria may apply, whichever are most favorable to the veteran. At the outset it is again noted that service connection for organic heart disease has been denied on earlier occasions, most recently by the Board in 1989. The veteran has a history of significant disability from non-service-connected organic heart disease. Supraventricular tachycardia and atrial fibrillation as manifestations of organic heart disease are not service connected. Sinus tachycardia is service-connected only as functional manifestation of his service-connected psychiatric disorder. 38 C.F.R. § 4.14. Disability attributable to manifestations not the result of service-connected disability may not be considered in support of an increased compensation rating for his service-connected psychiatric disorder. Id. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only as it affects earning capacity. 38 C.F.R. § 4.129 (effective prior to November 7, 1996); 38 C.F.R. § 4.126 (effective November 7, 1996). In this case the veteran is not working; he retired at the end of 1981 at age 63; and there is some difficulty in assessing occupation impairment from the psychiatric condition since the veteran has not attempted work since he retired. Although the veteran says he retired early because of his psychiatric condition, such is not shown by historical records. Some of the veteran's statements are also to the effect that his "service-connected" heart disease was a factor in his retirement, but, as noted, he is not service connected for organic heart disease. Moreover, some of the recent medical statements which opine that the veteran is unemployable from his "service-connected" disability are at least partly based on the erroneous assumption that organic heart disease has been service connected. In any event, in reviewing this case, the Board has focused on occupational and social impairment due exclusively to the service- connected psychiatric condition. The VA and private medical examination and treatment records from 1992 to 1999 contain various descriptions of psychiatric symptoms and various assessments (including GAF scores) of social and industrial impairment from PTSD/anxiety. Assessments have ranged from moderate, to moderately severe, to severe, to total impairment from the psychiatric condition. The evidence shows the veteran is receiving regular psychiatric care, and some of the medical records refer to social isolation. The Board is left with the overall impression that in recent years (and many years after the veteran retired from work) there has been a deterioration in his mental health to the extent that psychiatric symptoms might now well prevent him from obtaining or retaining employment (even assuming he had no physical ailments and was a younger man seeking a job). In the judgment of the Board, the evidence is about equally divided as to whether the veteran's service-connected PTSD/anxiety reaction is now productive of total occupational or social impairment, such as would warrant a 100 percent rating under either the old or new rating criteria. Under such circumstances, the veteran is given the benefit of the doubt, and the Board concludes that a 100 percent rating for the psychiatric disability is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7; Gilbert v. Derwinski, 1 Vet. App 49 (1990). ORDER An increased 100 percent rating for a service-connected psychiatric disorder is granted. L. W. TOBIN Member, Board of Veterans' Appeals