BVA9506311 DOCKET NO. 93-08 786 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a skin disorder. 2. Entitlement to service connection for chronic stomach disorder, including irritable bowel syndrome. 3. Entitlement to service connection for defective hearing. 4. Entitlement to service connection for tinnitus. 5. Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: Hugh F. Daly, Attorney WITNESSES AT HEARINGS ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD J. W. Loeb, Counsel INTRODUCTION The veteran served on active duty from October 1965 to July 1967. This case was remanded by letter by the Board of Veterans' Appeals (Board) in October 1993 to the Department of Veterans Affairs(VA) Regional Office (RO) in Cleveland, Ohio, so that the veteran might have a personal hearing before a traveling member of the Board, which was conducted in March 1994. For reasons which shall become clear, the Board is assuming jurisdiction over the matter of an increased rating for PTSD. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that, based on the medical evidence on file, his service-connected PTSD is severe enough to warrant a 100 percent schedular evaluation. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. 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 supports the grant of a 100 percent schedular evaluation for PTSD. FINDINGS OF FACT 1. Satisfactory effort has been made to obtain all relevant evidence necessary to an equitable determination of the issue of entitlement to an evaluation in excess of 50 percent for PTSD. 2. The veteran has totally incapacitating psychoneurotic symptoms, due to his PTSD, that result in virtual isolation in the community and render him demonstrably unable to obtain or retain substantially gainful employment. CONCLUSION OF LAW The criteria for a 100 percent schedular evaluation for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. Part 4, §§ 4.7, 4.132, Diagnostic Code 9411 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim for an evaluation in excess of 50 percent for PTSD is well-grounded within the meaning of 38 U.S.C.A. § 5107(a) because it is not inherently implausible. Additionally, the facts relevant to this issue have been properly developed and the statutory obligation of the VA to assist the veteran in the development of this issue has been satisfied. 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When 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 (1994). According to the Schedule for Rating Disabilities, a 50 percent evaluation is provided for PTSD when the veteran's psychoneurotic symptoms result in considerable social and industrial impairment; a 70 percent evaluation is provided for PTSD when the veteran's psychoneurotic symptoms result in severe social and industrial impairment; and a 100 percent evaluation is provided when psychiatric symptomatology results in virtual isolation in the community and there are 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 explosion of aggressive energy resulting in profound retreat from mature behavior, with the veteran demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9411. According to a September 1989 medical report from Sagi H. Raju, M.D., the veteran was first seen in August 1989 because of severe anxiety, feelings of helplessness, and depression. The veteran said that he had never been able to put his Vietnam experience behind him. He said that he was unable to relax, that he stayed at home almost all of the time, that he had difficulty sleeping, and that he was easily angered and could fly into a rage over even something simple. The veteran's mood was described as severely anxious, worried, and impulsive. His attitude was of indifference and anger, with inappropriate reactions to situations. He was thought to have a poor ability to relate to other people. Dr. Raju concluded that the veteran had a severe form of bipolar affective disorder, with possible PTSD, severe ineffective individual coping skills, and a severe anxiety disorder. The veteran was considered disabled for at least a year. The doctor had last seen him in early September 1989. A December 1989 Disability Determination of the Social Security Administration reveals that the veteran was awarded disability benefits for anxiety related disorders, based on Dr. Raju's report. On VA compensation examination in July 1990, the veteran noted Vietnam related nightmares 4-5 times a week, Vietnam flashbacks in the form of hearing helicopters, extreme irritability, previous suicidal ideation and gestures, and the loss of multiple jobs due to his behavior. He said that he had had problems with the police because of fighting and arguments with his neighbors. On mental status examination, the veteran's affect was constricted and his mood was depressed. He admitted to suicidal ideation but no plan. The assessment was severe PTSD that prevented the veteran from being able to function at even a minimal level and a dysthymic disorder secondary to PTSD. He was considered to have an ongoing chronic stressor of moderate degree and a Global Assessment of Functioning score of 65. VA psychiatric examination in December 1992 revealed that the veteran spent most of his time watching sports on television. He said that he felt guilty about surviving Vietnam and that he got very anxious whenever a helicopter flew overhead. He said that his service in Vietnam had ruined his life. He indicated that he still "hit the dirt" when startled. He said that he lost his last job and went to pieces when his boss touched him from behind and the veteran went into a rage. The psychiatric diagnosis was PTSD, with impairment considered moderately severe with active startle response, chronic anxieties, disturbed sleep, and employment problems based on his startle response. The prognosis was poor. According to a February 1994 Psychological and Vocational Evaluation report from Kenneth J. Manges, Ph.D., which was an extensive evaluation based on a review of the complete record, the veteran had not worked since 1980. Dr. Manges noted that the veteran's behavior was unpredictable and dangerous, that he was depressed and limited in his ability to concentrate, and that he had worked as a laborer and had no transferability of skills to alternative employment. Dr. Manges concluded that the veteran had severe PTSD, that he had 100 percent psychological impairment, and that remunerative employment was out of the question. The veteran testified at his personal hearing before a traveling member of the Board in March 1994 that he was taking medication for his psychiatric disease, that he had Vietnam flashbacks and nightmares approximately twice a week, that he only got about 3.5 hours sleep a night, that he hated crowds and only left his house about once a week, that he had problems with memory and concentration, that he spent most of his time in his basement sitting and looking out of the window, and that he had been violent in the past towards his wife. Testimony from the veteran's wife at the March 1994 hearing reiterated what her husband had said. According to a January 1995 letter from a VA physician who had worked with the veteran for two years in the local Mental Hygiene Clinic, the veteran had suffered a severe emotional injury as a result of his combat experiences. It was noted that the veteran was functioning at a remarkably high level despite the fact that he would never be able to be gainfully employed. It was also noted that it took all of the veteran's energy to manage his moodiness and recurrent traumatic states so that he could have a little peace at home with his family. The above evidence reveals that the veteran has PTSD symptomatology that causes almost total isolation in the community, with the veteran spending much of his time by himself in his basement. The recent medical reports on file, especially the February 1994 report from Dr. Manges, attest to the severity of the veteran's PTSD symptoms and to his inability to work due to his PTSD. His frequent problems with flashbacks and nightmares of Vietnam, difficulty getting a good night's sleep, depression and anxiety, irritability and anger, and startle response show that his symptomatology more nearly approximates the criteria for a 100 percent evaluation for PTSD, as he seems to have totally incapacitating psychoneurotic symptoms that render him demonstrably unable to obtain or retain employment. 38 C.F.R. §§ 4.7, 4.132, Diagnostic Code 9411. ORDER Entitlement to a 100 percent schedular evaluation for PTSD is granted, subject to the controlling regulations applicable to the payment of monetary benefits. REMAND It was contended on behalf of the veteran in November 1992 that his skin disorder and his stomach disorder were either incurred in service or as a result of his service-connected PTSD, either due to PTSD-related stress or to the medication prescribed for this disorder. The veteran testified at his personal hearing in March 1994 that his skin disorder is probably chloracne due to service exposure to Agent Orange. See Hearing Transcript at page 16. The Board finds that the issues of entitlement to secondary service connection for a skin disorder and a stomach disorder, which have not been addressed by the RO, are inextricably intertwined with the certified issues of entitlement to direct service connection. Harris v. Derwinski, 1 Vet.App. 180 (1991). Therefore, additional development is required prior to final disposition of this case. Consequently, this case is remanded to the RO for the following actions: 1. The veteran should be permitted to submit any additional evidence that is pertinent to the issues on appeal. He should be requested to provide the names, addresses, and dates of treatment of any physicians or facilities, including the VA, that have treated him for a skin disorder, irritable bowel syndrome, a stomach disorder, defective hearing, or tinnitus since service discharge. Any medical provider identified should be asked for copies of the veteran's clinical records not currently on file. Any records obtained should be associated with the claims folder. The veteran should be asked to sign any necessary consent forms for release of his private medical records. 2. The veteran should be afforded a special dermatological examination by a board certified specialist, if available, to determine the nature and severity of any current skin disability. All necessary tests and studies should be conducted, and all findings should be reported in detail. The examiner should offer an opinion as to whether it is at least as likely as not that any current skin problem is causally related to service, including exposure to Agent Orange, or to the veteran's service- connected PTSD, including his use of medication therefor. The rationale for all opinions expressed should be fully explained. The claims folder must be made available to the examiner for review before his examination of the veteran. 3. The veteran should be afforded a special gastrointestinal examination by a board certified gastroenterologist, if available, to determine the current nature and severity of any gastrointestinal disability, including irritable bowel syndrome. All necessary tests and studies, including x-rays, should be conducted, and all findings should be reported in detail. The examiner should give an opinion whether it is at least as likely as not that any current gastrointestinal disability, if found, is causally related to either the veteran's military service or his service- connected PTSD, including medication use. The rationale for all opinions expressed should be fully explained. The claims folder must be made available to the examiner for review before examination of the veteran. 4. The veteran should be afforded a special audiometric examination to determine the current nature of any hearing loss and tinnitus. All necessary tests and studies should be conducted, and all findings should be reported in detail. The examiner should give an opinion whether it is at least as likely as not that any current defective hearing or tinnitus is causally related to the veteran's exposure to acoustic trauma as an infantryman during service. The rationale for all opinions expressed should be fully explained. The claims folder must be made available to the examiner for review before examination of the veteran, with special attention called to the veteran's service medical records, which show that he had defective hearing in the left ear at 4000 hertz on entrance examination in September 1965. 5. Thereafter, the RO, based on all of the evidence of record, should readjudicate the issues on appeal and adjudicate the inextricably intertwined issues of entitlement to secondary service connection. After the above actions have been completed, if the benefits sought are not granted, a supplemental statement of the case should be issued to the veteran and his representative on all issues in appellate status and they should be given an opportunity to respond or appeal, as appropriate. The case should then be returned to the Board. The veteran need take no action until notified. J. J. SCHULE Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a (CONTINUED ON NEXT PAGE) determination. This proceeding has been assigned to an individual member of the Board. 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) (1994).