Citation Nr: 0004377 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 96-18 074 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for ischemic heart disease as a residual of beriberi. 2. Entitlement to an increased evaluation for service- connected anxiety reaction, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. A. Herman, Associate Counsel INTRODUCTION The veteran had active military service from December 1942 to October 1945. He was a prisoner of war (POW) of the German Government from April 24, 1944 to May 3, 1945. This appeal arises from a February 1996 rating decision of the Pittsburgh, Pennsylvania, regional office (RO) which denied service connection for ischemic heart disease due to beriberi and which denied a disability evaluation greater than 50 percent for the veteran's service-connected anxiety reaction. A review of the claims folder indicates that the issue of entitlement to service connection for beriberi was previously considered and denied by the Board of Veterans' Appeals (Board) in May 1982. Thereafter, the law as it relates to POWs was liberalized under Pub. L. No. 97-37, 95 Stat. 935-37 (codified at 38 U.S.C.A. § 1112(b)). When a provision of law or regulation creates a new basis of entitlement to veteran benefits, as in this case currently before the Board, a claim under the new law is a claim separate and distinct from the claim previously denied prior to the liberalizing law or regulation. See Spencer v. Brown, 4 Vet. App. 283 (1993). Accordingly, the Board will review the present claim for service connection for ischemic heart disease as a residual of beriberi on a de novo basis. Suttman v. Brown, 5 Vet. App. 127 (1993). FINDINGS OF FACT 1. The veteran has been diagnosed as having ischemic heart disease. 2. The evidence of record suggests that the veteran experienced edema of his lower extremities as a POW. 3. The symptoms of the veteran's anxiety reaction are not manifested by more than considerable social and industrial impairment. 4. The veteran has not routinely displayed 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 worklike setting); and an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. Incurrence of ischemic heart disease during active military service is presumed. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). 2. The criteria for an evaluation in excess of 50 percent for the service-connected anxiety reaction have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. § 3.321 and Part 4, including §§ 4.1, 4.2, 4.7, 4.10 (1999), 4.129, 4.130, 4.132, Diagnostic Code 9400 (as in effect prior to November 7, 1996), Diagnostic Code 9400 (as in effect on or after November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's enlistment examination indicated that his cardiovascular system was normal. The service medical records do not contain a repatriation examination. In September 1945, the veteran was admitted to the hospital due to complaints of nervousness and an inability to regain lost weight. He stated he had had similar attacks of nervousness while interned as a POW. He reported that his normal weight was 155 pounds. At that time, he weighed 135 pounds. An examination of his vascular system indicated that he had good tone. His heart was normal in size, shape, rate, and rhythm. There were no murmurs. His blood pressure was 140/75. Following a psychiatric examination in September 1945, the veteran was diagnosed as having severe anxiety-type psychoneurosis. He was transferred to a convalescent hospital, where he received a diagnosis of recovered severe chronic anxiety type psychoneurosis due to combat and his POW experiences. On an October 1945 Report of Physical Examination pending service discharge, the veteran's cardiovascular system was found to be normal. His feet and musculoskeletal system were free of defects. His blood pressure was 130/78. There were no findings pertaining to beriberi or edema. The veteran filed a claim of service connection for a psychiatric disorder in January 1948. At that time, he submitted an October 1947 letter from a private physician who reported that he had examined the veteran in August 1947 and that he had found him to have a systolic blood pressure of 160 and a very irregular heart beat and to be significantly underweight. The physician stated that he had advised the veteran to stop working immediately. In March 1948, the veteran was afforded a VA general medical examination. He reported losing between 20 and 30 pounds of weight while being held as POW. He stated that his best weight had been 168 pounds in 1944. He denied experiencing dysentery or abdominal cramps. He said he had occasionally had diarrhea. The veteran complained of nervousness, fatigue, and abdominal pain. His cardiovascular system was normal. His blood pressure was 136/78. There were no findings pertaining to edema. A separate psychiatric examination included a diagnosis of severe chronic anxiety-state psychoneurosis with slight improvement. In addition, the examiner described the degree of the veteran's incapacity as moderate to severe. By a rating action dated in March 1948, the RO granted service connection for a chronic anxiety state and assigned a 30 percent evaluation to this disability, effective from January 1948. The rating for this service-connected disability was subsequently increased to 50 percent in April 1980. Between 1948 and 1982 the veteran filed several claims for service connection for various conditions. The evidence obtained in connection with those claims included reports of VA medical examinations, VA treatment records, personal statements, and reports from private physicians. Of note is an October 1974 statement from a private physician who reported that the veteran had had essential hypertension since 1972. A similar history was recorded during a January 1975 VA general medical examination. At the time of the 1975 examination, no evidence of murmur, arrhythmia, or edema was shown. Pedal pulses were "ok." The veteran's blood pressure was 170/110 in the sitting position, 174/104 in the recumbent position, and 158/110 in the standing position. As part of a November 1977 claim of service connection for disabilities resulting from his POW experiences, the veteran reported that he experienced "leg and feet problems" during his internment. He did not elaborate as to the exact nature of these problems. However, in an attached 80 page hand- written statement, he discussed his POW and post-military experiences in detail. He indicated that he suffered numerous minor injuries as a result of his capture and that he had been given an inadequate supply of food throughout his captivity. No reference was made to any swelling or edema of his lower extremities. In a letter dated in July 1979, a private physician reported that he had examined the veteran for the purpose of determining whether he suffered from beriberi and that the veteran had come under his care in November 1977 at which time the veteran gave a history of being a POW for 14 months and explained that there was a questionable history of beriberi secondary to poor nutrition while a POW. The physician also said that the veteran had symptoms of causalgia and chronic neuritis of the feet, that these symptoms were thought to be part of a beriberi picture, and that the veteran was, therefore, treated with Stresstabs and injections of B Complex for four weeks. The physician also reported that the veteran experienced a dramatic improvement in his causalgia and neuritis symptoms. The physician stated that no laboratory confirmation of the diagnosis of beriberi or B-1 deficiency had been made because such studies were not available to his practice and that, as such, the veteran had been treated empirically. The veteran was afforded a personal hearing before the RO in August 1980. At that time, he asserted that he had had beriberi and suffered from malnutrition during his internment. He said that he had experienced a significant weight loss as a POW. He averred that he currently suffered from neurological problems of the lower extremities, that those problems were related to beriberi, and that he is receiving routine private medical treatment for his beriberi (in particular, monthly shots of B-12 to alleviate those symptoms). He submitted several "buddy statements" from fellow service members who had been interned with the veteran. Those individuals recalled that the veteran suffered from malnutrition and leg problems while being held as a POW. The veteran's leg problems were noted to have been related to injuries suffered when he "bailed out" and landed on some rocks. In an October 1980 statement, a private physician reported that the veteran had a history of hypertension, burning of the bottoms of the feet, and painful knees. He also indicated that the veteran had experienced recurrent tachycardia since 1965. In December 1980, the veteran was afforded a VA neurological examination in order to explore his complaints of beriberi. He complained of neurological deficits and weakness in his lower extremities. He stated that the symptoms were related to beriberi and that he was receiving treatment for the same from a private physician. His in-service history of weight loss was discussed. Following a physical evaluation, the veteran was diagnosed as having long-standing sensory disturbances of an unestablished etiology. The examiner stated that it was doubtful that beriberi explained those symptoms. Service connection for beriberi was denied by the Board in May 1982. The Board held that there was no evidence that the veteran suffered from beriberi in service or post-service. The Board noted that a VA examiner had specifically indicated that it was "doubtful" that the veteran's complaints of a neurological disorder of his lower extremities were due to beriberi. Medical records from the Pittsburgh VA Medical Center (VAMC) dated from May 1990 to June 1991 have been associated with the claims folder. These records show that the veteran received evaluations and treatment for, but not limited to, coronary artery disease and the residuals of a cerebral artery branch infarct. A May 1990 discharge summary indicated that the veteran underwent a coronary artery bypass graft in March in 1990 and that he suffered a cerebral vascular accident a few days later. The veteran was also noted to have had a history of hypertension and transient ischemic attacks. No findings were made with regard to his military service. In June 1995, the veteran filed a claim of service connection for a heart condition secondary to his POW experiences. He also indicated that he deserved a higher evaluation for his service-connected psychiatric disorder. The veteran was afforded a VA psychiatric examination in September 1995. He stated that he spends much of his time watching television and that he is able to engage in simple household chores such as sweeping, dusting, and making his bed. He denied having any hobbies. Since having a stroke, he stated that he has been unable to read due to memory loss. The veteran's mood and affect were good, and he laughed easily. He denied depression or anxiety. However, he did indicate that he becomes easily frustrated when undertaking a task that takes longer than it should. Hallucinations and delusions were absent. He stated he no longer suffers from nightmares and that he is no longer "angry all the time." The veteran was oriented, but his concentration and memory were severely impaired, and his insight and judgment were also impaired. The examiner provided Axis I diagnoses of an anxiety disorder not otherwise specified and rule out dementia. Additionally, the examiner assigned to the veteran a score of 45 on the Global Assessment of Functioning (GAF) scale. Furthermore, the examiner indicated that one of the veteran's Axis III diagnoses included coronary artery disease. By a rating action dated in February 1996, the RO continued the 50 percent disability evaluation assigned to the veteran's service-connected anxiety reaction. The RO explained that there were no findings of the necessary symptomatology to support a higher evaluation. By the February 1996 rating action, the RO also denied service connection for ischemic heart disease secondary to beriberi. The RO observed that there was an unlimited presumptive period for granting service connection for beriberi heart disease to include ischemic heart disease for veterans who have been held as POWs for 30 days or more. As there was no evidence showing that the veteran suffered from beriberi or the symptoms of beriberi, to include edema, during his internment, the RO determined service connection was not warranted. In a statement received in June 1996, the veteran reported that he suffered from severe swelling of the feet and legs while being held as a POW. He recalled being evaluated for the swelling problem by a physician. He said that he was told that the condition would improve with time. Additionally, the veteran explained that he was provided a scant amount of food during his internment as a POW and that this lack of food resulted in severe malnutrition. The veteran was afforded another VA psychiatric examination in December 1996. He was somewhat taken aback at the idea that he was there for an examination of his psychiatric disorder and essentially denied having any current psychiatric problems. Prior to having two strokes in 1990, he stated he had had difficulties with nightmares and restlessness during sleep. He also claimed that he had been constantly anxious. However, the veteran reported that most of his symptoms had disappeared since his strokes. His wife said that he had no difficulty sleeping, that his temper was good, that he was not bothered by nightmares, and that he did not appear depressed. The veteran's main complaints pertained to an inability to recall information that he had previously reviewed and being physically jittery most the time. He stated that he had worked as a baker until his retirement in 1976, that he had been married twice, and that he had been married to his current wife for 11 years. On mental status examination, the veteran was alert and roughly oriented in all three spheres. There was no evidence of psychosis. It was very apparent that he had difficulty recalling things, especially recent events. He had also some difficulty with word search and tended to speak circumstantially. The veteran's mood was euthymic. His affect appeared to be responsive and well modulated. The overall impression was clearly one of dementia that was probably of the multi-infarct type and effected the veteran's verbal expressiveness and memory. While there appeared to a history of post-traumatic stress disorder (PTSD), the examiner stated that he could not find "hide nor hair" of said disorder. He said the veteran's PTSD was either in remission and/or being overshadowed by the affective, personality, and cognitive changes related to his strokes. Consequently, the examiner provided an Axis I diagnosis of multi-infarct type dementia which was mild to moderate in intensity. Additionally, the examiner diagnosed (on Axis I) moderate PTSD by history which was currently in remission and/or overshadowed by the affective, personality, and cognitive changes of organicity. The Axis III diagnoses, as stipulated by the examiner, included coronary artery disease and coronary artery bypass graft surgery. In August 1998, the 50 percent disability rating assigned to the veteran's service-connected anxiety reaction was continued. The RO observed the criteria for evaluating mental disorders had been revised during pendency of the veteran's appeal. In that regard, the RO found that the evidence of record did not show that a 70 percent disability evaluation was warranted under either the old, or the new, rating criteria. A supplemental statement of the case mailed to the veteran in April 1998 contained citations to the new rating criteria. (In this regard, the Board notes that the statement of the case which was furnished to the veteran in March 1996 provided him with the old rating criteria.) II. Analysis A. Service Connection At the outset, the Board notes that the veteran's claim for service connection for ischemic heart disease as a residual of beriberi is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the Board finds that the veteran has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the military, naval, or air service. 38 U.S.C.A. § 1110 (West 1991). Where a veteran served 90 days or more during a period of war, and cardiovascular disease to include hypertension becomes manifest to a degree of 10 percent or more within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Further, if a veteran is: (1) A former prisoner of war and; (2) as such was interned or detained for not less than 30 days, the following diseases shall be service-connected if manifest to a degree of 10 percent or more at any time after discharge or release from active military, naval, or air service even though there is no record of such disease during service, provided the rebuttable presumption provisions of § 3.307 are also satisfied. Avitaminosis. Beriberi (including beriberi heart disease). Chronic dysentery. Helminthiasis. Malnutrition (including optic atrophy associated with malnutrition). Pellagra. Any other nutritional deficiency. Psychosis. Any of the anxiety states. Dysthymic disorder (or depressive neurosis). Organic residuals of frostbite, if it is determined that the veteran was interned in climatic conditions consistent with the occurrence of frostbite. Post-traumatic osteoarthritis. Irritable bowel syndrome. Peptic ulcer disease. Peripheral neuropathy except where directly related to infectious causes. Note: For purposes of this section, the term beriberi heart disease includes ischemic heart disease in a former prisoner of war who had experienced localized edema during captivity. 38 C.F.R. § 3.309(c). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the U.S. Court of Appeals for Veterans Claims (Court) held that "a veteran need only demonstrate that there is an "approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. It is the Board's responsibility to weigh the evidence. The Board also has the duty to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997) and cases cited therein. Here, the record shows that the veteran has had a history of cardiovascular problems since the mid-1960s. His problems have included hypertension and tachycardia. More recently, he has submitted evidence showing that he has been diagnosed as having coronary artery disease. Coronary artery disease as well as arteriosclerotic heart disease have been found to be synonymous with ischemic heart disease. See Veterans Benefits Administration (VBA) Circular 21-97-1 (June 17, 1997). In other words, there is current medical evidence showing that the veteran has a diagnosis of ischemic heart disease. There is also evidence that the veteran suffered from edema while a POW. In a statement received in June 1996, the veteran expressly indicated that he suffered from swelling of the feet and legs during his captivity. Statements from the veteran dated in 1977 and personal testimony in 1980 also contained discussion of leg and feet problems at the time he was a POW. Moreover, statements obtained from fellow POWs referenced the veteran's complaints of leg problems during his internment (albeit these problems were noted to have been caused by injuries related to a parachute landing). The Board recognizes that the veteran's service medical records contain no findings of complaints of edema. However, VA must accept the statements of former POWs about disabilities or diseases incurred during confinement as proof of incurrence so long as residual disability is found that can be attributed to the alleged service incident. Moreover, no mention of any claimed disability need appear in service records. See VA Adjudication Procedure Manual, Manual M21-1, Part VI, Paragraph 7.23(c)(3) and (5). As an alternative, in claims pertaining to service connection for ischemic heart disease, statements by veterans on POW questionnaires during protocol examinations are deemed to be relevant and probative in determining whether or not the veteran suffered from edema during captivity. VBA Circular 21-97-1. There is no record that the veteran was ever afforded a POW protocol examination or given the opportunity to complete a POW questionnaire. Thus, while there is no clear evidence prior to 1996 suggesting that he suffered from edema of the legs and feet during captivity, the Board finds that this lack of evidence fails overcome the veteran's personal statements of his experiences at that time. Thus, given the fulfillment of the two primary criteria (the presence of in-service edema and a post-service diagnosis of ischemic heart disease), the facts are sufficient to support a grant of service connection for that ischemic heart disease as having been the result of the veteran's POW experience in service under appropriate presumptive regulations. B. Increased Evaluation The first inquiry must be whether the appellant has stated a well-grounded claim for an increased evaluation as required by 38 U.S.C.A. § 5107(a). A well-grounded claim is one that is plausible. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In the context of a claim for an increased evaluation of a condition adjudicated service connected, an assertion by a claimant that the condition has worsened is sufficient to state a plausible, well-grounded claim. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). The appellant in the instant case has stated a well-grounded claim. Moreover, as all evidence necessary for an equitable disposition of the veteran's claim was obtained by the RO, the VA has fulfilled its duty to assist. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.159 (1999). Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for evaluation of the complete medical history of the claimant's condition 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 v. Derwinski, 1 Vet. App. 589 (1991). Moreover, the VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. 38 C.F.R. § 4.10 provides that the basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Whatever system is affected, evaluations are based upon lack of usefulness of these parts or systems, especially in self-support. The medical examiner must therefore furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, a full description of the effects of disability upon the person's ordinary activity. At the outset, the Board notes that the criteria used to determine the extent to which psychiatric disorders are considered disabling were changed, effective November 7, 1996. To that extent, the record shows that the veteran has had notice of the old and new criteria for evaluating anxiety disorder. In determining which version of the regulations to apply to the facts of this case, the Board notes that the Court has held that where the law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant will apply unless Congress provided otherwise or permitted the Secretary of Veterans Affairs (Secretary) to do otherwise and the Secretary did so. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). In this instance, neither Congress nor the Secretary has directed which regulations are to be applied under the circumstances of this case. Accordingly, the version most favorable to the appellant will be considered. Under the old provisions, in evaluating impairment resulting from psychiatric disorders, social inadaptability was to be evaluated only as it affected industrial adaptability. The principle of social and industrial inadaptability, the basic criterion for rating disability from the mental disorders, contemplated those abnormalities of conduct, judgment, and emotional reactions which affect economic adjustment (that is--impairment of earning capacity). 38 C.F.R. § 4.129 (as in effect prior to November 7, 1996). The severity of disability was based upon actual symptomatology, as it affected social and industrial adaptability. Two of the most important determinants of disability were time lost from gainful employment and decrease in work efficiency. The VA could not under evaluate the emotionally sick veteran with a good work record, nor could it over evaluate his or her condition on the basis of a poor work record not supported by the psychiatric disability picture. It was for that reason that great emphasis was placed upon the full report of the examiner which was descriptive of actual symptomatology. The record of the history and complaints was only preliminary to the examination. The objective findings and the examiner's analysis of the symptomatology were the essentials. 38 C.F.R. § 4.130 (as in effect prior to November 7, 1996). Social inadaptability under the previous criteria was to be evaluated only as it affected industrial impairment. 38 C.F.R. § 4.132 (as in effect prior to November 7, 1996). When evaluating a mental disorder, under the new criteria, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. When evaluating the level of disability from a mental disorder, 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 (as in effect on November 7, 1996). The veteran is currently assigned a 50 percent disability rating for his service-connected anxiety reaction. The now superceded regulation governing the rating of mental disorders, 38 C.F.R. § 4.132, provided that where an anxiety disorder was manifested by active psychotic manifestations of such extent, severity, depth, persistence or bizarreness as to produce total social and industrial inadaptability, a 100 percent disability evaluation was warranted. Where there was lesser symptomatology such as to produce severe impairment of social and industrial adaptability, a 70 percent evaluation was warranted. A 50 percent rating contemplated considerable social and industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (as in effect prior to November 7, 1996). The "new" regulations pertaining to rating psychiatric disabilities, in effect as of November 7, 1996, are set forth in pertinent part below: General Rating Formula for Mental Disorders: 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. 70 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. 50 38 C.F.R. Part 4, Diagnostic Codes 9201-9440 (1999). Upon review of the claims file, the Board finds that an evaluation in excess of 50 percent is not warranted under either the "old" or "new" rating criteria. Again, a 70 percent evaluation under the old criteria was assignable when the anxiety disorder caused severe impairment of social and industrial adaptability. The veteran's poor employment history must therefore be viewed in its entirety. The record indicates that the veteran has not worked since 1976. In this regard, he reported retiring after working as a baker for over 30 years. He did not attribute his retirement to his service-connected psychiatric disorder nor did he attribute it to his continued unemployment. Moreover, at the 1995 and 1998 VA examination psychiatric examinations, the veteran stated that he had experienced a significant decrease in the symptoms related to his service-connected anxiety disorder. Since suffering two strokes in the early 1990s, the veteran stated he no longer suffered from the nightmares and anxiety that had been previously associated with his psychiatric disorder. The report of the 1998 VA examination indicated that the symptoms of the veteran's anxiety disorder/PTSD were either in remission or overshadowed by the residuals of his cerebral vascular accident. Further, the record shows that the veteran suffers from physical impairments, to include the residuals of a stroke, that have, at the very least, impacted his ability to work. There is no indication that the veteran's service-connected psychiatric anxiety disorder has severely affected his ability to work. With regard to social impairment, the veteran has demonstrated that he currently maintains a long-standing personal relationship with his wife. The report of the September 1995 VA psychiatric examination seems to suggest that the veteran and his wife enjoy a healthy relationship and share in the duties of the household. While he reports that he no longer drives, reads, or engages in any hobbies, these deficits were attributed to being residuals of his cerebral vascular accidents. The Board finds that the evidence fails to support a finding of severe social impairment. In other words, the requirements for a 70 percent disability rating under the "old" rating criteria have not been met. Moreover, viewing the veteran's disability picture under the "new" criteria, the Board is also unable to find that a rating in excess of 50 percent is warranted. The veteran has not routinely displayed symptoms of 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 an inability to establish and maintain effective relationships. In other words, none of the symptoms required to evaluate the veteran's anxiety disorder as 70 percent disabling (pursuant to the "new" rating criteria) are not present. Consequently, the Board concludes that the preponderance of the evidence is against the claim of entitlement to a disability rating in excess of 50 percent for the veteran's service-connected anxiety reaction (under either the "old," or the "new," rating criteria). The Board has also considered the assignment of a higher evaluation in this case on an extra-schedular basis under 38 C.F.R. § 3.321(b)(1). A basis for an extra-schedular evaluation is not shown, however, as the service-connected anxiety disorder does not result in marked interference with employment or frequent periods of hospitalization, or otherwise present an exceptional or unusual disability picture. ORDER Entitlement to service connection for ischemic heart disease is granted. Entitlement to an increased evaluation for service-connected anxiety reaction, currently evaluated as 50 percent disabling, is denied. THERESA M. CATINO Acting Member, Board of Veterans' Appeals