Citation Nr: 0007355 Decision Date: 03/20/00 Archive Date: 03/23/00 DOCKET NO. 94-31 522 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an increased evaluation for anxiety neurosis, currently evaluated as 30 percent disabling. 2. Entitlement to an increased evaluation for neuritis of the left elbow, residual of a shell fragment wound with retained foreign body, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Grace Jivens-McRae, Counsel INTRODUCTION The veteran served on active duty from October 1942 to October 1945. This appeal arises from a May 1993 rating decision of the Philadelphia, Pennsylvania, Department of Veterans Affairs (VA) Regional Office (RO), which confirmed and continued a 30 percent evaluation for anxiety neurosis and a 10 percent evaluation for neuritis of the left elbow. FINDINGS OF FACT 1. The veteran's anxiety neurosis is productive of considerable and no greater social and industrial impairment, according to regulations in effect prior to November 7, 1996 and subsequent thereto. 2. The veteran has not routinely displayed symptoms such as: obsessional rituals which interfere with routine activities; impaired impulse control (such as unprovoked irritability with periods of violence); speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and an inability to establish and maintain effective relationships; nor is severe impairment in social and industrial relationships shown. 3. Neuritis of the left elbow is productive of no more than mild incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a 50 percent evaluation and no more for anxiety neurosis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.129, 4.130, 4.132 Diagnostic Code 9400 (before and after November 1996). 2. The criteria for a rating in excess of 10 percent for neuritis of the left elbow have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, Diagnostic Code 8616 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background The veteran served on active duty from October 1942 October 1945. He sustained shrapnel wounds in the region of the left elbow in October 1944. By rating decision of December 1945, service connection was granted for neuritis, residuals of wound of the left elbow. A 30 percent evaluation was assigned. By rating decision of February 1947, the veteran's service connection evaluations were amended on receipt of clinicals received by the RO. The rating for neuritis, residuals of wound of the left elbow, remained the same. Service connection was granted for psychoneurosis, anxiety state. A noncompensable evaluation was assigned, effective from October 1945. By rating decision of December 1949, the RO noted that a November 1949 VA examination showed the veteran's neuritis of the left elbow had improved with no limitation of motion in the joint and no findings of atrophy involvement of the ulnar nerve, wholly sensory. It was determined that a reduction to 10 percent from 30 percent should be made. The veteran was notified by letter of the same month of the RO's intention to reduce his rating for his left elbow from 30 percent to 10 percent. His noncompensable evaluation for anxiety neurosis was confirmed and continued. He was given a period of 60 days to submit any evidence to show why the reduction should not be made. No evidence was received by the RO in 60 days and the reduction took place. By rating decision of August 1983, the veteran's rating for neuritis of the left elbow was confirmed and continued. The evaluation for his anxiety neurosis was increased from noncompensable to 10 percent, effective February 1983. By rating decision of January 1989, the RO implemented a January 1989 Board of Veterans' Appeals (Board) decision increasing the veteran's evaluation for anxiety neurosis from 10 percent to 30 percent, effective March 1987. The 10 percent evaluation for neuritis of the left elbow was confirmed and continued. These evaluations remain in effect to this date. In February 1993, a January 1993 medical statement from Charles J. Aquilina, MD, was received by VA in support of the veteran's claim. He related that the veteran had been under his medical management for 10 years. He related that the veteran had multiple medical problems to include anxiety neurosis (combat related). He stated that the veteran had progressive worsening and deterioration of his mental status. It was Dr. Aquilina's opinion that the veteran required increasing psychological encouragement; he had become more withdrawn and less sociable and that as his anxiety neurosis progressed, for all practical purposes, it interfered with his normal everyday activities. In April 1993, the veteran underwent a VA neurology examination. It was noted that there was a one-inch scar on the medial side of the veteran's left elbow. It was noted that apparently there was ulnar nerve damage, and he had a decreased pain and light touch sensation on the medical aspect from the elbow to the mid forearm. The veteran complained that grip strength had been decreasing for years. At the time of the examination, his strength was about 4/5. There appeared to be no other abnormal findings. There was full range of motion of the remainder of the peripheral joints. Wrist function was normal and the veteran was able to button buttons and pick coins off the desk. The diagnosis was ulnar nerve neuropathy secondary to shrapnel wound. Also in April 1993, the veteran underwent a VA psychiatric examination. The veteran complained of tiredness and interrupted sleep. He stated that he was plagued with nightmares and flashbacks. He also observed that lately he was unable to socialize. He did not even want to go out with his daughter. He was depressed most of the time and somewhat pessimistic. Mental status examination revealed the veteran had a somewhat sad facial expression. His memory was slightly impaired for recent and past events. He had nightmares, flashbacks, few friends and wanted to be by himself. He used to fish, but gave up that activity. He tried to read books, but became nervous and started to pace. He was coherent, relevant and oriented. His intelligence was normal and his mood was slightly depressed. His affect was somewhat shallow. The examiner stated that it was his opinion that the veteran needed more medication. He noted that the veteran was seen by a psychologist once a month. He spoke with the veteran's psychologist who claimed the veteran was "very nervous and anxious." The veteran had some insight into his condition and his judgment was fair. He was not homicidal or suicidal at the time of the examination. The diagnosis was generalized anxiety disorder with post- traumatic stress disorder (PTSD) features. The Global Assessment of Functioning (GAF) Scale score was 70/60. His social and industrial impairment was described by the examiner as moderately severe. The veteran provided personal hearing testimony before a hearing officer at the RO in September 1994. He related that he was in receipt of Social Security Administration disability benefits (he submitted an award letter) because he had no more physical or mental control as a machinist. He stated that he was "screwing up" parts, his left arm was getting weak and he could no longer control his thinking. He stated that he was under a lot of pressure at work. He stated that he had not received treatment for his left elbow for a while but was scheduled to be seen for his elbow in October 1994. He testified that he had no feeling under the arm, no grip in his left hand and he had lost all of the power in his left hand. He stated that in the morning, his left arm was completely numb and he was unable to lift anything. He indicated that he was not on any medication for treatment of his left elbow. As for his psychiatric disability, he testified that he would go to the mall with his brother for coffee twice a week; see a lady friend at the mall just to say "hi", every three weeks, and see his daughter once a week. He stated that this was substantially different than before as he was previously in a Polka Club, and this was something he no longer did. VA outpatient treatment records from December 1994 to December 1995 for the veteran's left hand and elbow were associated with claims folder. These records showed that the veteran underwent nerve conduction studies and an EMG after complaints of left hand weakness and pain. The impression of the EMG was that there was evidence of bilateral carpal tunnel syndrome superimposed on a peripheral neuropathy. He also was seen every six months in the orthopedic clinic for evaluation of Duputyren's disease of the left extremity. The examiner stated that there was no need for surgery and it was recommended that he continue to treat the disease with passive stretching. The veteran underwent a VA neurology examination in August 1995. He complained of numbness of the hands, more in the ulnar aspect. Physical examination showed that the veteran was alert and oriented. There was power equal on both sides, except that hand grasp may have been slightly weaker on the left side, but the examiner did not see Froment's sign. There was no focal muscle atrophy. Muscle strength reflex was symmetrical but hypoactive. Percussion of the median nerve at the wrist showed no definite evidence of Tinel sign. The thenar side on the right side appeared relatively flabby. The diagnostic impression was that the veteran had clinical as well as electrophysiological evidence of diffuse peripheral neuropathy which could be diabetic in origin. His previous EMG study showed superimposed carpal tunnel syndrome. The examiner stated that he had reviewed the nerve conduction study and the segment close to the elbow on the left side of the left ulnar nerve was relatively slow as compared to that of the segment below. The examiner related that the veteran probably had superimposed ulnar nerve neuropathy at the level of the elbow on the left side. Also in August 1995, the veteran underwent a VA psychiatric examination. He related that he continued to have a significant degree of insomnia and difficulty sleeping with interrupted sleep, two to three times a week. He stated that his sleep was interrupted by flashbacks and vivid dreams. Since his last examination, he related that he noticed that he was becoming less sociable. He previously went to the mall three times a week and now rarely went more than once a month. He also related that he used to go dancing regularly with a lady friend but he rarely went anymore. His medication had been increased. He had minimal contact with his children. He also related that when he got anxious, he had a more difficult time concentrating. He experienced more difficulty with noises and loud sounds. He complained of depression, feeling low and preoccupation with financial matters. Mental status examination revealed the veteran to be alert and oriented. His memory was fair to good. His mood was anxious and depressed. Affect was appropriate to his mood. There were no delusions or hallucinations. He had no homicidal ideation but expressed intermittent thoughts of harming himself without specific plan. There did not appear to be any evidence of psychosis. His insight and judgment appeared to be fair. The diagnosis was generalized anxiety disorder with depressive features. His GAF was somewhere in the vicinity of 60, 58, 55. According to the examiner, it appeared that the veteran's social impairment was getting worse from his last VA compensation examination. The veteran underwent a VA orthopedic examination in September 1996. He complained of left hand pain with some numbness. He also complained of some numbness involving the right hand. He was also concerned because of some lumps in the palm of his left hand that sometimes became tender. He noted that his grip strength was a little less than it had been in the past and he dropped things involving the left hand. Physical examination revealed that testing of all dermatomes of the upper extremities, left and right, was equal and normal. He had a little Tinel's over the median nerve on the right side and over the ulnar nerve on the right side. There was no Tinel's over the left median or ulnar nerve. He had a full range of motion. There was Dupuytren's disease on the fourth flexor tendon area, but there was no contracture or MCP or PIP levels. At the time of the examination, he had full supination and pronation. The examiner recommended that the veteran needed to use a soft sponge or gripper to work on his strength. In September 1997, the veteran underwent a VA orthopedic examination. The veteran complained that his left extremity disability has worsened with weakness in the arm and numbness in the left hand. Examination of the left arm showed a well- healed, irregular scar on the inner side of the left elbow measuring 1 inch in length. There were no other scars on the left arm. Range of motion of the left arm was normal as with the other arm. Flexion was accomplished to 120 degrees and extension was accomplished to 0 degrees. There was also normal range of pronation and supination as compared to the uninjured right arm. The muscles in left arm were approximately 1/4 inch smaller than the uninjured right arm. The examiner stated that this was a normal differential for a right-handed person, so that there was no muscle atrophy in the long muscles of his arms, nor was there any atrophy of the intrinsic muscles of the hand. He had a mild Dupuytren's palmar fascia contraction in the left hand that he felt might be related to his left elbow injury, however, the examiner explained to the veteran that this was a separate problem that was completely unrelated and very mild, which required no treatment. He was able to fully open and close all of his fingers and the thumb of both hands. He reported some sensory losses in the arm but no motor loss. The examiner stated that there were no signs that supported the veteran's complaint of weakness of grasp in the arm. X-rays showed a single triangular piece of shrapnel approximately 1 cm. at its widest in the soft tissue on the volar aspect of the elbow. The examiner stated that it was just a little deeper than the skin and could be removed except that it did not appear to be causing any problems. There were no inflammatory signs around it. It was not anywhere near the ulnar nerve; it was a little toward the radial side in the soft tissue just under the skin. The examiner stated that the veteran did not have any clinical signs of ulnar nerve damage at least from a motor aspect, in that there was no wasting of the muscles supplied by the ulnar nerve. The examiner stated that the veteran had some sensory losses that he related to the injury which was purely speculative. Objectively, the physical findings were quite good, and would not, in the examiner's opinion, limit the use of the veteran's left arm in any significant manner. It was the examiner's opinion that the veteran could do about anything physically that a man of his years and muscular development would permit. The veteran also underwent a VA neurology examination in September 1997. He complained of numbness of the left hand, ulnar aspect. He related that he had a history of shrapnel injury in the left forearm area. Physical examination showed the veteran was right-handed with no dysphasia, dysarthria, or cranial carotid bruit. Evaluation of the motor system showed power to be equal on both sides. There was no definite sensory deficit. Muscle stretch reflex was symmetrical, bilaterally. No pathological reflex. There was no evidence of Froment's sign. Examination of the hands revealed some evidence of Dupuytren's contracture of the left hand. There was no definite muscle weakness of the ulnar aspect of the left forearm area. In October 1997, the veteran underwent a VA psychiatric examination. It was noted that the veteran was on active outpatient care at the VA mental hygiene clinic. He had been on therapy over 20 years and his medication was supervised by a VA psychiatrist at the same time. He was noted to see a VA psychologist on a once-a-month basis. It was noted that he had never been hospitalized psychiatrically. He complained that he worried a lot which was triggered by any small thing. He also complained of insomnia and disturbance of concentration. For six months, he complained of depressive feelings with occasional crying spells. He admitted to passive suicide ideation with no plan or intent. He also reported distressing memories about his World War II experiences. He related that he went to church three times a week in addition to his clinic visits. He admitted to socializing once in a while with his brothers, but had no worthwhile hobbies. Mental status examination revealed the veteran was alert and oriented. He was well groomed and neat with good personal hygiene. His demeanor was anxious to some degree with hand wringing. His affect was appropriate. His mood was depressed and his speech was generally normal and coherent. He had no psychotic symptoms in the form of delusions and hallucinations. His thought processes were goal directed. He was free of suicidal or homicidal ideation during the examination, although he expressed some passive suicidal thoughts intermittently without any plans or intent in the past. His test of cognition was generally intact. His remote and recent memory was intact. His judgment was not grossly impaired. His insight was good. The pertinent diagnosis was generalized anxiety disorder with features of depression. The GAF was 55 for the past year and at the time of the examination his GAF was 45. The examiner stated that the veteran had severe social and occupational impairment on account of persistent anxiety complicated by a mild to moderate depression over the past six months. VA outpatient treatment records dated from July 1993 to October 1997 showed that the veteran had been seen in the mental hygiene clinic on an ongoing basis for treatment for chronic anxiety and depression. Throughout that period, the veteran's chronic anxiety was noted to increase and later be in fair control. He was noted to respond with support. Most recently, in July 1997, his mild depression and anxiety was determined to be partially controlled. It was noted that he went on vacation to Maryland and enjoyed himself. However, in October 1997, the examiner described the veteran as still "worrisome." He continued to have disturbed sleep and feelings of depression. He related he had no hobbies and he did not feel like doing anything. At that time, his medication was increased. Analysis The veteran and his representative assert that the veteran's anxiety neurosis and neuritis of the left elbow are more severe than the current evaluations reflect. At the outset, it is important to determine if the veteran has established well-grounded claims for increased evaluations for anxiety neurosis and neuritis of the left elbow, that is, ones that are plausible. 38 U.S.C.A. § 5107(a) (West 1991). A claim for an increased evaluation is a well-grounded claim if the claimant asserts that a condition for which service connection has been granted has worsened. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In this case, the veteran has asserted that his service-connected anxiety neurosis and neuritis of the left elbow are more severe than currently evaluated. Therefore, he has established well-grounded claims. Having satisfied this burden, VA has a duty to assist in the development of facts pertinent to this claim. The Board is satisfied that all relevant facts in this case have been properly developed. The veteran has been seen on an outpatient basis for both his anxiety and his neuritis of the left elbow. He presented personal hearing testimony before a hearing officer at the RO in September 1994. Finally, he has undergone VA compensation and pension examinations for both disabilities as recently as September and November 1997. The record is complete, there is no further duty to assist in the development of this claim as mandated by 38 U.S.C.A. § 5107(a). 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 that 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter under consideration, the benefit of the doubt in resolving the issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 1991). Furthermore, 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. The 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 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, 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 conclusions. Some of the basic facts are not in dispute. Service connection is in effect for anxiety neurosis rated under the provisions of Diagnostic Code 9400. VA Schedule for Rating Disabilities, 38 C.F.R. Part 4. Service connection was established for psychoneurosis, anxiety state by rating decision of February 1947. A noncompensable evaluation was assigned, effective October 1945. By rating decision of October 1983, the veteran's disability was recharacterized as anxiety neurosis and increased from noncompensable to 10 percent, effective February 1983. By rating decision of January 1989, the RO implemented a Board decision increasing the veteran's evaluation for anxiety neurosis from 10 percent to 30 percent. The 30 percent evaluation is still in effect to this date. Service connection was granted for neuritis, residuals of a wound of the left elbow by rating decision of December 1945. A 30 percent evaluation was assigned, effective from October 1945. By rating decision of December 1949, it was determined that a reduction to 10 percent from 30 percent should be made because clinical records indicated that the veteran's neuritis of the left elbow had improved. The veteran was notified by letter of the same month of the RO's intention to reduce his rating for his left elbow from 30 percent to 10 percent. He was given a period of 60 days to submit any evidence to show why the reduction should not be made. No evidence was received by the RO in 60 days and the reduction took place. The 10 percent evaluation for neuritis of the left elbow remains in effect to this date. Anxiety Neurosis 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 disorders. In determining which version of the regulations to apply to the facts of this case, the Board notes that the U.S. Court of Appeals for Veterans Claims (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. The version most favorable to the appellant will therefore 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; in other words, the 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 from November 7, 1996). The veteran is currently assigned a 30 percent disability rating for anxiety neurosis. Prior to November 1996, a 30 percent rating for a generalized anxiety disorder was assigned when there was definite impairment in the ability to establish or maintain effective and wholesome relationships with people, and the psychoneurotic symptoms result in such a reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. A 50 percent rating was assignable when the ability to establish and maintain effective or favorable relationships was considerably impaired, and, by reason of psychoneurotic symptoms, the reliability, flexibility, and efficiency levels were so reduced as to result in considerable industrial impairment. A 70 percent rating was assignable when the ability to establish and maintain effective or favorable relationships with people was severely impaired. The psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. 38 C.F.R. Part 4 Diagnostic Code 9400. In Hood v. Brown, 4 Vet. App. 301 (1993), the Court stated that the term "definite" as utilized in 38 C.F.R. § 4.132 was "qualitative" in character, whereas the other descriptive terms were "quantitative" in character, and invited the Board to "construe" the term "definite" in a manner that would quantify the degree of impairment for purposes of satisfying the Board's statutory duty to articulate the "reasons and bases" for its decision under 38 U.S.C.A. § 7104(d)(1) (West 1991). The Board subsequently requested an opinion from the Office of the General Counsel of the VA. In a precedent opinion dated November 9, 1993, the General Counsel concluded that the term "definite" is to be construed as denoting "distinct, unambiguous, and moderately large in degree." It represents a degree of social and industrial impairment that is "more than moderate but less than rather large." O.G.C. Prec. 9-93 (Nov. 9, 1993). The Board is bound by this interpretation of the term "definite" when applying the provisions of 38 C.F.R. § 4.132, Diagnostic Code 9411. 38 U.S.C.A. § 7104(d)(1) (West 1991). The "new" regulations pertaining to rating psychiatric disabilities, in effect as of November 7, 1996, are set forth in pertinent part below: 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 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 30 38 C.F.R. § Part 4 Diagnostic Codes 9201-9440 (1999). After reviewing the foregoing evidence, the Board finds that the veteran's anxiety neurosis is such that it warrants an increased rating to 50 percent under both the new criteria and old criteria. The veteran's service-connected psychiatric disability has resulted in occupational and social impairment with reduced reliability and productivity. He has stated that he is constantly depressed, has significant insomnia and that his family and social environments are strained. At his most recent VA psychiatric examination in October 1997, his demeanor was anxious and he was noted to wring his hands. He admitted that he still had passive suicide ideation on an intermittent basis. His mood was depressed. His GAF Scale score was 45, which is indicative of, among other things, serious difficulty in social or occupational functioning, an example of which is suicidal ideation, no friends and an inability to keep a job. (See American Psychiatric Association: Quick Reference to the Diagnostic Criteria from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994.). Over a period of the last few years, his medication has continuously been increased. Although the evidence supports a finding of occupational and social impairment with reduced reliability and productivity warranting a 50 percent evaluation under the old and revised criteria, an evaluation in excess of 50 percent under either criteria is not warranted. Again, a 70 percent rating is assignable when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. To that extent, these new regulations require finding 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); inability to establish and maintain effective relationships. There is no evidence of record that establishes that the veteran's anxiety neurosis has had such a broad reaching influence on his life. Moreover, the symptoms associated with a 70 percent evaluation have not been demonstrated. He appeared neatly dressed and groomed. His thought processes appeared normal. By his own report, he was capable of maintaining his personal hygiene and other basic activities of daily living. Although he does not cook for himself, he is capable of going out and obtaining his own meals and he cleans his own home and clothes. There were no findings of obsessional rituals or near- continuous panic. Furthermore, there is sufficient evidence that shows that the veteran is able to establish and maintain effective relationships. The Board concedes that the veteran's relationship with his family has been strained. However, he testified at a September 1994 personal hearing that he does see his brother at the mall for weekly coffee. More recently, he indicated he socializes with his brothers once in a while. Nevertheless, most of the symptoms required to evaluate the veteran as 70 percent disabling are not present. Moreover, while the veteran's occupational and social impairment have somewhat affected his mood and relationship with his family, the record clearly shows that his ability to relate with others, judgment, and thinking have remained relatively intact. Similarly, under the criteria for evaluating psychiatric disorders effective prior to November 1996, entitlement to an evaluation in excess of 50 percent has not been demonstrated. As noted above, a 70 percent evaluation under the old criteria was assignable when the ability to establish and maintain effective or favorable relationships with people was severely impaired and when the psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. Accordingly, the reasons for the veteran's current unemployment must be viewed in their entirety. The record clearly indicates that the veteran retired from being a mechanic in the early 1980s. He reported that he could not handle his position any longer as a result of his physical and psychiatric disabilities. However, at that time, his anxiety neurosis was rated as only 10 percent disabling. At present, the veteran has numerous disabilities, most of which are not service-connected. Moreover, there is no evidence of record that shows that the veteran is presently unable to work due to his service- connected anxiety neurosis. With regard to social impairment, the record clearly shows that the veteran currently maintains a relationship with his children, albeit strained. He socializes with a brother once in a while. He has also reported that he regularly attends church. Thus, the Board finds that the evidence supports a finding of considerable but no greater social impairment. Thus, in considering the criteria prior to November 1996, there is no evidence that the veteran's anxiety neurosis has caused a severe impairment of his industrial capacity. Based on the foregoing, the veteran's symptomatology is reflective of findings warranting a higher evaluation of 50 percent, but no more for his service connected anxiety neurosis. Neuritis of the Left Elbow Peripheral neurological conditions are to be rated with consideration of the site and character of the injury and of the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120 (1999). Peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for the injury to the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123 (1999). The residuals of the veteran's shrapnel wound of the left elbow are currently evaluated as 10 percent disabling under Diagnostic Code 8616, neuritis of the ulnar nerve. This is the appropriate rating for minor, incomplete paralysis for a minor and major extremity. The veteran is right-handed, and this is considered his major extremity. However, the disability is of his left elbow which is considered his minor extremity. In order to warrant a 20 percent evaluation for a minor extremity, moderate, incomplete paralysis must be shown. Severe, incomplete paralysis, warrants a 30 percent evaluation for a minor extremity. A review of the medical evidence shows that the veteran's left elbow neuritis exhibits pain and weakness of the left hand. His range of motion and muscle strength were essentially the same in his service-connected left extremity and nonservice-connected right extremity. His most recent VA neurology examination in September 1997 showed no definite weakness of the ulnar aspect of the left forearm area. Further, an orthopedic examination performed at the same time showed no clinical signs of ulnar nerve damage. The examiner stated that there were no signs that supported the veteran's complaint's of weakness of grasp in the arm. Moreover, the veteran attempted to attribute his mild Dupuytren's palmar fascia contraction to his left elbow injury. The examiner explicitly stated that this was a separate, unrelated condition which required no treatment. Based on the foregoing, which showed the veteran's neuritis resulted in no more than mild disablement, an increased evaluation for neuritis of the left elbow is not warranted. ORDER A 50 percent evaluation and no more for anxiety neurosis is granted, subject to the laws and regulations pertaining to the payment of monetary benefits. An increased evaluation for neuritis of the left elbow, residual of a shell fragment wound with retained foreign body, is denied. BARBARA B. COPELAND Member, Board of Veterans' Appeals