Citation Nr: 0001571 Decision Date: 01/19/00 Archive Date: 01/28/00 DOCKET NO. 98-11 327 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased rating for post traumatic stress disorder (PTSD), currently evaluated as 50 percent. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Ferrandino, Associate Counsel INTRODUCTION The veteran had active service from February 1968 to February 1970. By rating decision in May 1994, service connection was granted for PTSD. This appeal arises from the June 1998 rating decision from the Columbia, South Carolina Regional Office (RO) that granted the veteran a temporary total rating based on hospitalization effective from March 24, 1998 followed by the assignment of a 50 percent schedular rating from June 1, 1998. A Notice of Disagreement was filed in June 1998 and a Statement of the Case was issued in July 1998. A substantive appeal was filed in July 1998 with a request for a hearing at the RO before a local hearing officer. In October 1998, the above-mentioned RO hearing was held. FINDINGS OF FACT 1. The veteran's claim for an increased rating for PTSD is plausible. 2. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 3. The veteran's PTSD results in total occupational and social impairment. CONCLUSIONS OF LAW 1. The veteran has stated a well-grounded claim concerning an increased rating for PTSD. 38 U.S.C.A. § 5107(a) (West 1991). 2. The Department of Veterans Affairs has satisfied its duty to assist the veteran. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1999). 3. An evaluation of 100 percent for PTSD is warranted. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.126, 4.130, Diagnostic Code 9411 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's DD Form 214 indicates that he served in Vietnam and was awarded the Combat Infantry Badge. His only service- connected disability is PTSD. By a May 1994 rating decision, the RO, in pertinent part, granted service connection for PTSD, and assigned a 30 percent rating for this condition, effective from September 1993. In April 1998, the veteran wrote to the VA and indicated that he had been hospitalized for his PTSD. A report of VA hospitalization from March to May 1998 is of record. On admission, the veteran presented a history consistent with chronic PTSD in severe exacerbation. On mental status examination, he appeared aloof, withdrawn, tense and anxious. He reported hearing voices or something related to Vietnam, making him upset, paranoid and isolated most of the time. He also reported reliving experiences such as constant intrusive recollections and thoughts and reported emotional avoidance, numbness and phobias. He was hesitant to speak to others. He indicated that, at times, his depression related to intrusive thoughts was so severe at times that he thought of killing himself. He exhibited irrational fears, guarded affect and paranoid ideations with frequent checking and looking back over his shoulders. He was hypersensitive to loud noises. Startle response was noted to loud noises. He was hypervigilant. Affect was sad and flat while talking about his experiences in Vietnam. He appeared anhedonic and pessimistic about the future. He denied current thoughts of hurting himself or others. On VA hospital discharge, his symptoms were still noted to be severe and persistent. He was in good control of self and reality. He exhibited no violent thoughts or severe depression. He was oriented times three with intact attention, concentration and memory. While the veteran was reported to be competent, it was noted he was unemployable due to severe, chronic and persistent symptoms of PTSD. Records of outpatient treatment at the VA during June 1998 show continuing treatment for PTSD. It was reported that the veteran's PTSD was marked by poor coping skills and impaired level of functioning; i.e., depression, intrusive thoughts, anger and nightmares. He had social isolation due to PTSD. In July 1998, a licensed clinical psychologist with a Ph.D. degree who is employed by the VA reported that he had treated the veteran for several years. He reported that the veteran was inflexible and inefficient, with a reduced persistence and pace. This was especially evident when severe anxiety, anger or irritability was present. During such periods, the veteran experienced depression, extreme social withdrawal and angry acting out. The emotional peaks made cognitive functioning such as memory, concentration, attention, comprehension and judgment unreliable and unpredictable. These symptoms would make it very difficult for the veteran to function on any regular, day to day, full-time job. In October 1998, the veteran appeared for a hearing before the RO. He reported, among other things, having panic attacks, two to three times per week. He indicated he lived alone and had very few friends. He denied having any social life. In February 1999, a medical report was received from the VA clinical psychologist referred to above. The veteran's symptoms were reported to be anxiety, depression, sleep disturbance, anger and irritability. It was noted that he was medically retired from a civil service job. The assessment was that the veteran's PTSD was chronic and severe and resulted in unemployability. A GAF (General Assessment of Functioning) score was 45. II. Analysis The first responsibility of a claimant is to present a well- grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). A claim for an increased evaluation is well grounded 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 the symptoms of his PTSD are worse than evaluated by the RO. He has thus stated a well-grounded claim. VA has a duty to assist the veteran in the development of facts pertaining to his claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1999). The United States Court of Veterans Appeals (Court) has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal. The duty to assist is neither optional nor discretionary. Littke v. Derwinski, 1 Vet. App. 90 (1990). It may include providing the veteran with a medical examination to determine the nature and extent of his disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The undersigned finds that the medical evidence of record is sufficient for an equitable determination in this case. In view of the decision below, the veteran will not be prejudiced by not being afforded a current VA examination for rating purposes. In addition, although the RO has not had the benefit to review a current VA medical record, the favorable action in this case again precludes any prejudice to him. 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. § 3.321(a) and 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. 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 regulations pertaining to rating psychiatric disabilities were revised effective November 7, 1996, prior to the veteran filing his current claim. The "new" regulations pertaining to rating psychiatric disabilities, in effect as of November 7, 1996, are found in 38 C.F.R. § 4.130, Codes 9201-9440 (1999) and are set forth, in pertinent part, below: General Rating Formula for Mental Disorders: 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. 100 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. § 4.130, Diagnostic Code 9411 (1999). Upon review of the claims file, the Board finds that an evaluation of 100 percent is in order. The evidence is at least in equipoise that the veteran has total occupational and social impairment. This is confirmed by the hospital report and the reports of the VA clinical psychologist. Despite treatment, he continues to suffer from anxiety, depression, intrusive thoughts, anger and nightmares. In addition, there is social isolation and thoughts of harming himself and others. His memory is affected by his disability, and he suffers from paranoia. There are reports of hearing voices. In summary, his PTSD has so affected his daily activities as to be totally disabling. ORDER Entitlement to a rating of 100 percent for PTSD is granted, subject to the applicable criteria governing the payment of monetary benefits. Iris S. Sherman Member, Board of Veterans' Appeals