Citation Nr: 0000183 Decision Date: 01/05/00 Archive Date: 12/28/01 DOCKET NO. 98-05 035 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 70 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD B.E. Jordan, Counsel INTRODUCTION The veteran had active military service from April 1966 to April 1968. This appeal to the Board of Veterans' Appeals (Board) arises from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. FINDINGS OF FACT 1. All of the evidence necessary for an equitable disposition of this matter has been obtained. 2. Service-connected PTSD is manifested by total social and industrial impairment. CONCLUSION OF LAW The criteria for a disability evaluation of 100 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.130, Diagnostic Code 9411 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim is plausible and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (a claim of entitlement to an increased evaluation for a service-connected disability generally is a well-grounded claim). The Board is satisfied that all relevant evidence has been obtained with respect to this claim and that no further assistance to the veteran is required in order to comply with the duty to assist mandated by statute. 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 veteran's service medical records and all other evidence of record pertaining to the history of the veteran's service- connected PTSD and has found nothing in the historical record that would lead to a conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories and findings pertaining to the disability at issue. See Francisco v. Brown, 7 Vet. App. 55 (1994) (where an increase in a disability rating is at issue, the current level of disability is of primary concern). The record reflects that the veteran served in the Republic of Vietnam and received the Purple Heart commendation metal. VA treatment records dated in 1996 and 1997 show that the veteran was seen for symptoms associated with PTSD including flashbacks, nightmares, guilt, and irritability. A progress note dated in January 1997 reflects that the veteran's affect was tense and guarded, that he was cooperative, that he was neat and well groomed, and that he had experienced visual hallucinations. It was noted that the veteran had been referred to a PTSD program. He was hospitalized at a VA facility from January to March 1997 for PTSD. An admission report provided that the veteran had attended a 30-year reunion with his outfit and that he experienced increased PTSD symptoms thereafter. The record also reflects that the veteran had not had prior treatment for PTSD. The veteran related that he drank heavily for about 35 years and that he stopped after a drinking binge during the reunion. The diagnoses included Axis I-PTSD, alcohol abuse in remission. A Global Assessment of Functioning (GAF) score of 60 was assigned. A private medical record dated in March 1997 reflects that the veteran was seen for symptoms including insomnia, night sweats, night terrors, and depression. In a rating action dated in July 1997, the RO granted service connection for PTSD. A 10 percent disability evaluation was assigned, effective in November 1996. In May 1997, the veteran was hospitalized at a VA facility for PTSD. The veteran was admitted voluntarily to participate in a serial cerebrospinal fluid sampling study for PTSD. The veteran was discharged from the hospital in good condition with minor physical discomforts. The diagnosis was PTSD, research patient. The veteran was seen by VA in August 1997 and September 1997. The report of a VA compensation and pension examination dated in August 1997 reveals, in pertinent part, that the veteran had a history of alcohol abuse, that he had discontinued drinking a few months ago, that he was separated from his wife of 28 years, and that he was living with his daughter. It was recorded that the veteran last worked about 11/2 years ago and that he had held multiple employment positions since separating from service. The veteran reported symptoms including an inability to sleep, uncontrollable rage which resulted in property damage, verbal abuse toward his children, physical abuse, continuous dreams and flashbacks of the war, and panic attacks from having been lost in the woods. The veteran related that he had convinced himself that he was loosing his mind and that he had seen North Vietnamese soldiers in the woods. It was noted that the veteran did not have any friends and that he was isolated from people. He was close only to his immediate family. The veteran reported that he attended a reunion, but did not desire to be close to anyone. On a mental status examination, the veteran was described as being in good physical health and appearing to be younger than his stated age. The examiner observed that the veteran was agitated and that he wrung his hands during the interview. He avoided eye contact and appeared to be anxious. The veteran exhibited such symptoms because he had not been taking his medication in preparation for medical studies. The veteran was depressed, cynical, and bitter about his Vietnam experiences. There was no evidence of psychotic thought mood, or perceptual disorder. The veteran thought of suicide. Sensorium and memory were grossly intact, although the veteran spoke in a hesitating manner because of his discomfort. The veteran was not considered homicidal; however, the examiner believed that the veteran could be dangerous to other people. If provoked, it was noted that the veteran could easily damage property and engage in fights. The diagnoses included Axis I-PTSD, alcohol in remission; Axis IV-severe; very little income or limited ability to work, inadequate support system, financial difficulties, and separation from spouse. As to a GAF score, the examiner recorded an evaluation of approximately 15. It was noted that the veteran was in danger of hurting himself or others-a probability exacerbated by the fact that the veteran has been off of his medication. The examiner stated that the veteran was employed for awhile, but discontinued the employment because the woods reminded him of Vietnam. The veteran was considered competent for VA purposes. In September 1997, the veteran was voluntarily admitted to a VA facility to participate in a cerebrospinal fluid sampling study of PTSD. He was discharged home in excellent condition. In November 1997, the RO continued the 10 percent disability evaluation for PTSD. The veteran appealed that rating action. VA medical records dated in 1998 reflect that the veteran underwent therapy for his PTSD. Group therapy records dated from February to August 1998 provide symptoms including depression, nightmares about Vietnam, and isolation. These records also reflect that the veteran was reluctant to engage in discussions in the presence of new members until they spoke. A March 1998 entry shows that the veteran had met with a friend and discussed Vietnam and that the discussion adversely affected the veteran for about three days. These records disclose that the veteran occasionally socialized with his Marine friends. In June 1998, increased symptoms were noted after the veteran had returned from a reunion. In July, the veteran expressed displeasure with structure. As a result, he discontinued group therapy sessions and was transferred to individual sessions. It was also noted that the veteran saw the movie, "Saving Private Ryan" which disturbed him. An August 1998 entry reflects that the spouse of one the veteran's friend had died and that the veteran had planned to visit the bereaved friend. At a personal hearing dated in September 1998, the veteran testified before a hearing officer regarding his claim. Essentially, the veteran stated that his disability was more disabling than currently evaluated. He stated that he had not been employed for the past 2 years. He elaborated that he was last employed cutting timber and that being in the wood reminded him of being in Vietnam. He was employed for 25 years. He stated that he did not have a social life, but that associated with a few Marine buddies. In September 1998, the RO increased the veteran's disability evaluation for PTSD to 30 percent. That evaluation was effective to November 1996. The RO also granted a 100 percent evaluation pursuant to 38 C.F.R. § 4.29 which became effective in January 1997. That evaluation was reduced to 30 percent beginning in April 1997. When seen by VA in December 1998, the veteran reported extreme irritability. The veteran related an incident whereby he killed the family dogs their barking caused him to become enraged. The veteran stated that he was somewhat intoxicated at the time of those incidents. Additional complaints included difficulty concentrating while driving and interrupted sleep habits. As to enjoyment, the veteran indicated that he worked out at home and that he walked early in the morning to avoid contact with other people. He denied having a history of suicidal ideation. The veteran stated that he was not hopeful about the future. He denied homicidal ideation. He did not watch war movies. There was no history of mania. The veteran denied any history of auditory hallucinations. He had diminished interest and did not feel close to anyone. The veteran described feelings of always being on guard and startle response. He reported increased severity of symptoms since a 30-year reunion which was approximately 2 to 3 years ago. On a mental status examination, the veteran was casually dressed and relatively well kept. He demonstrated anxiety from the beginning of the examination. The examiner questioned the veteran's anxiety level. The veteran was oriented to place. His orientation to time was questionable. His speech was anxious, but not pressured. His thoughts were disjointed; he recalled the current president; he could not recall the preceding president without assistance. He accomplished simple addition with some difficulty. He reported that his anxiety prevented him from performing subtraction calculations. The veteran demonstrated difficulty spelling certain words due to his anxiety level. His motor movements were persistently restless. His affect was anxious and occasionally agitated. When asked what he would do if he were to find a letter on the sidewalk, the veteran indicated that might leave the letter in that it might be booby-trapped. The diagnoses were Axis I-PTSD, history of alcohol dependence; Axis IV- psychosocial and environmental stressors which were considered moderate based on limited financial resources and limited social interaction. GAF scores ranging from 20-25 were recorded. The examiner reiterated that the veteran endorsed diminished interest in activities, that he felt detached from others, that he exhibited a notably restricted range of affect and had no sense of any future, that he described difficulty sleeping, that he was irritable, that he had difficulty concentrating, that he felt as though he were always on guard, and that he had exaggerated startle response. The examiner noted that the veteran's prior use of alcohol had no bearing on the veteran's presentation during the examination. The examiner recorded that the veteran had some antisocial traits in terms of lack of remorse for having hit a person with a baseball bat and three armed robberies. It was noted that such antisocial behavior was exhibited in the past and did not impact on the veteran's current social functioning and ability to relate. The examiner concluded that the veteran's symptoms were attributable to PTSD and that the disorder was extremely severe. VA outpatient treatment records dated from 1998 to 1999 reflect that the veteran was seen for PTSD. In 1998, the veteran's symptoms ranged from depressed mood, restricted affect, isolation at home, a flashback while driving, good mood and affect, anxiousness, to teary affect. In February 1999, he reported continued isolation with no incentive to change and intrusive thoughts of the war. In March 1999, the veteran presented with depressed mood and repressed affected. He reported suicidal ideation, but thoughts of his grandchildren decreased any suicidal inclinations. In March 1999, the RO increased the veteran's disability evaluation to 70 percent which became effective in August 1997. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. 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 (West 1991); 38 C.F.R. §§ 4.1, 4.10 (1999). When evaluating a mental disorder, the rating agency considers the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during the periods of remission. An evaluation is assigned based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. The rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (1999). 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 the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Effective November 7, 1996, mental disorders, such as PTSD, are now assigned disability ratings based on a General Rating Formula for Mental Disorders described at 38 C.F.R. Part 4, § 4.130 (1999). That formula provides that occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms such 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 work-like setting); and inability to establish and maintain effective relationships will be rated as 70 percent disabling. 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 will be rated as 100 percent disabling. 38 C.F.R. Part 4, § 4.130, Diagnostic Code 9411 (1999). The record in this case shows that the veteran has psychiatric diagnoses that include PTSD and alcohol dependence by history. Of those psychiatric disabilities, service connection is in effect only for PTSD, and any disability stemming from the veteran's alcohol abuse cannot be considered in evaluating his disability as that condition was not sustained in line of duty and is considered the result of his own willful misconduct. 38 C.F.R. § 3.301(c)(2) (1999). The veteran's PTSD is currently rated as 70 percent disabling under 38 C.F.R. Part 4, § 4.130, Diagnostic Code 9411 (1999). In this matter, the evidence establishes that the veteran has social and industrial impairment. In that connection, the Board has considered and finds the veteran's testimony credible. While the evidence establishes that the veteran has some interpersonal interactions, such relationships are limited to his family and a few Marine buddies. In addition, the evidence shows that the veteran socially isolated without an intent to change, that he is detached from others, and that he is capable of harming others when angered. As to functioning abilities, the 1998 VA examination establishes that the veteran has high anxiety levels that interfere with his ability to conduct simple calculations and concentrate, and that he problems with orientation to time. With respect to industrial impairment, the veteran was forced to discontinue a position as a timber cutter because the woods reminded him of Vietnam. The Board also points out that the veteran was assigned a GAF score of 15 in 1997 and scores ranging from 20-25 in 1998. Based on the foregoing, the Board finds that the veteran's overall disability picture is more nearly reflective of total occupational and social impairment. Therefore, the assignment of a 100 percent disability evaluation is warranted. DC 9411; 38 C.F.R. § 4.7. ORDER A rating of 100 percent for PTSD is granted, subject to the criteria applicable to the payment of monetary benefits. BRUCE KANNEE Member, Board of Veterans' Appeals