BVA9503242 DOCKET NO. 91-52 446 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a cardiovascular disorder. 2. Entitlement to service connection for a prostate disorder. 3. Entitlement to an increased rating for chronic anxiety neurosis with conversion reaction, currently rated as 70 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD C. R. Olson, Counsel INTRODUCTION The veteran's active military service extended from May 1942 to October 1944. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1991 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. That rating decision, in part, continued a 50 percent rating for a chronic anxiety neurosis with conversion reaction, which had been in effect since November 1979. The rating decision also denied service connection for a cardiovascular disorder and a prostate disorder. The case was previously before the Board in June 1992, when it was remanded for examination of the veteran and medical opinions. The requested development was completed. A May 1994 survey by a social worker revealed dementia. In a June 1994 rating decision, the RO granted a 70 percent rating for the chronic anxiety neurosis with conversion reaction. The Board now proceeds with its review of the appeal. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the RO committed error in denying service connection for cardiovascular and prostate disorders. He avers that the disorders are due to his service-connected psychiatric disorder and that they had their inception and initial treatment during his active military service. The veteran further contends that his service-connected chronic anxiety neurosis with conversion reaction warrants a higher rating because it prevents him from working. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against service connection for cardiovascular and prostate disorders and that the evidence supports a 100 percent rating for the service-connected chronic anxiety neurosis with conversion reaction. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. The veteran's the service-connected chronic anxiety neurosis with conversion reaction precludes him from securing or following a substantially gainful occupation. 3. A cardiovascular disorder was not present in service or manifested in the first post service year. 4. The veteran's cardiovascular disorder is not shown to be the proximate result of disease or injury incurred during his active military service. 5. The veteran's prostate disorder was not present in service. 6. Cancer of the prostate was not manifested during service or within the first year following active service. 7. The veteran's prostate disorder is not shown to be the result of disease or injury incurred during his active military service. CONCLUSIONS OF LAW 1. The criteria for a 100 percent rating for a chronic anxiety neurosis with conversion reaction have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.16(c) and Code 9401 (1994). 2. A cardiovascular disorder was not incurred in or aggravated by active military service, may not be presumed to have been incurred in service and is not proximately due to or the result of a service-connected injury. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309, 3.310(a) (1994). 3. A prostate disorder was not incurred in or aggravated by active military service and is not proximately due to or the result of a service-connected injury and cancer of the prostate may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309, 3.310(a) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is to say that he has presented claims which are plausible. VA has assisted the veteran as much as it can in the development of his claim. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). I. Anxiety Neurosis with Conversion Reaction Service-connected disabilities are rated in accordance with a schedule of ratings which are based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). The service connected chronic anxiety neurosis with conversion reaction is currently rated as 70 percent disabling under diagnostic code 9401. That rating contemplates that the veteran's ability to establish and maintain effective or favorable relationships with people is severely impaired and the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. The next higher schedular rating, 100 percent, requires that the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community, and that there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior, with the veteran demonstrably unable to obtain or retain employment. 38 C.F.R. Part 4, Code 9401 (1994). A 100 percent rating may also be assigned where the only compensable service-connected disability is a mental disorder assigned a 70 percent evaluation, and such mental disorder precludes a veteran from securing or following a substantially gainful occupation. 38 C.F.R. § 4.16(c) (1994). An October 1944 rating decision granted service connection for psychoneurosis, hysteria, moderate, manifested by headaches, backaches, and sexual impotence. The hysteria psychoneurosis was noted on the report of the VA hospitalization in December 1944 and January 1945. On the October 1947 VA psychiatric examination, findings were normal except for poor judgment and insight. The diagnosis was psychoneurosis, anxiety state, severe. A November 1947 rating decision granted a 30 percent rating for the psychoneurosis. On a November 1948 VA examination, it was reported that the veteran had an anxiety reaction manifested by tachycardia, hyperhidrosis, tremulousness, frequency of urination, insomnia, faintness, and weakness. A December 1952 VA examination resulted in a diagnosis of conversion reaction manifested by weakness of the legs, with various somatic anxiety symptoms. On a July 1957 VA examination, the diagnosis was conversion reaction, chronic, moderate to severe, manifested by emotional tension, restlessness, anxiety, impatience, impulsiveness, and impairment of cutaneous sensibility below the level of the crest of each ilium. On a January 1980 VA examination, the veteran complained that he had tension, anxiety, disequilibrium and a loss of sensation over the left side of his body. He stated that he had lost his job as a cook because he kept dropping trays and would burn himself without knowing it. He displayed a moderate degree of anxiety and tension. His insight was considered poor. The diagnosis was a chronic anxiety neurosis with conversion reaction. A February 1980 rating decision increased the rating to 50 percent. Waxing and waning mental status and threats of suicide led to VA hospitalization from April to June 1986. Diagnoses included a chronic sedative (Valium) dependence, a substance induced (Valium) amnestic disorder, primary degenerative dementia, senile onset, panic disorder, and hysterical neuroses. A July 1987 VA examination concluded with a diagnosis of anxiety disorder with conversion features and organic brain syndrome, mild to moderate. The summary of the VA hospitalization in October and November 1987 shows diagnoses of atypical psychosis, chronic obstructive pulmonary disease, coronary artery disease, and adjustment disorder. VA clinical notes of 1990 and 1991 show treatment for the service-connected psychiatric disorder. On a January 1991 VA examination, the veteran was noted to be rather energetic and very animated. He spoke loudly with pressured speech. For the most part, his productions were relevant, connected and logical. His affect was appropriate and his mood was almost euphoric. He reported taking medication for his nervousness. He was oriented. There were some memory deficits. The diagnosis was a bipolar disorder, manic with psychotic features. The examiner commented that the diagnosis was by inference and seemed to be in remission. At his July 1991 RO hearing, the veteran reported taking medication and seeing a psychiatrist regularly. He described his daily activities. He told of his psychiatric symptoms and his relations with other people. He also spoke of his other disabilities. He said that he was house bound by his disabilities. The veteran's wife also described his symptoms and restrictions. On a November 1992 VA mental examination, The veteran spoke of headaches and said he was very nervous. The examiner noted an inability to remember dates and confusion of recent and remote memory. He told of hearing voices, difficulty sleeping, memory impairment, and fighting and arguing with others. The examiner considered the diagnosis of an organic mood disorder. A social worker interviewed the veteran in May 1994. The veteran complained of being depressed and nervous. He was not a very good historian and his speech was somewhat rambling. He appeared to have a generalized anxiety disorder and dementia. It was reported that his nervousness impacted on his ability to maintain employment. In July 1994, a VA physician reported a diagnosis of chronic anxiety disorder and senile dementia. The veteran's current functioning was reported to be 35. See Global Assessment of Functioning Scale (GAF), American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (3d ed. rev., 1987). The doctor commented that the dementia could occur with or without mental illness. Reportedly, the veteran's memory impairment would prevent him from following instructions required of most types of gainful employment. His difficulty in dealing with others would significantly interfere with his ability to communicate and cooperate with coworkers. The entire mental disability picture presented in this case is consistent with an inability to meet the demands of substantially gainful work. A nonservice- connected dementia is a factor in this impairment; however, none of the various examiners has attempted to separate the disability due to dementia from the disability due to the service-connected psychiatric disorder. The Board finds no way to reasonably dissociated the manifestations. Therefore, the Board finds that the psychiatric manifestations which render the veteran unemployable cannot be segregated from his service-connected disability. Consequently, the evidence shows that the service- connected disability renders the veteran unemployable. This warrants a 100 percent rating. 38 C.F.R. Part 4, including § 4.16 and Code 9401 (1994). II. Cardiovascular Disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(16), 1110 (West 1991). A cardiovascular disease, including hypertension, may be presumed to have been incurred during active military service if it is manifest to a degree of 10 percent or more within the first year following active service. 38 U.S.C.A. §§ 1101, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1994). Service connection may also be granted for a disability which is proximately due to and the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1994). The service medical records do not show the presence of any chronic cardiovascular disease. When the veteran was admitted to a hospital, in February 1944, his blood pressure was normal and his heart had a regular sinus rhythm without enlargement, murmurs or thrills. Examination on a hospital admission in July 1944 again showed a normal blood pressure. Heart sounds were of good quality without murmurs. An August 1944 x-ray study also showed a normal heart. The report of the VA hospitalization and examination in December 1944 and January 1945 shows that the cardiovascular system was normal with a normal blood pressure. There were also normal findings on the VA examinations in October 1946, November 1948, and December 1952. The earliest records of cardiovascular abnormality were in August and October 1978 VA clinical notes which showed elevated blood pressures. There were subsequent normal and elevated readings. On VA hospitalization for a urethral stricture, in January 1985, heart sounds, x-rays and an electrocardiogram were normal. In February 1985, the veteran was admitted to a private hospital complaining of chest pain. He developed a high grade atrioventricular block which required the placement of a permanent pacemaker. There was no evidence of myocardial infarction. The diagnosis was unstable angina and high degree AV block requiring permanent pacemaker. At his July 1991 RO hearing, the veteran provided inconsistent testimony. He initially reported that he did not have high blood pressure in service and later that he had it during his service years. He spoke of breaking out behind the ears and treatment with medication and needles. The psychiatric examiners have noted that the veteran is a very poor historian. The confused nature of the hearing testimony and the opinions of his doctors that he is a poor historian lead the Board to conclude that the veteran has not provided credible evidence of cardiovascular disease during service. The record clearly shows that cardiovascular findings were normal during service and for many years thereafter. Abnormalities were first manifested more than thirty years after the veteran's left active service. There is no medical evidence linking the post service disorder to any disease or injury during service. Therefore, the preponderance of the evidence must be viewed as demonstrating that cardiovascular disease was not the result of disease or injury during service and there is no basis to presume that it was incurred in service. It has been contended, in part, that the service-connected psychiatric disorder caused the cardiovascular disorder. The veteran has not submitted any medical opinion to support that assertion and his allegation is not competent evidence with respect to medical diagnosis or causation. See also Espiritu v. Derwinski, 2 Vet.App. 492 (1992), Grottveit v. Brown, 5 Vet.App. 91 (1993). In July 1994, a VA physician reviewed the record and expressed the opinion that the veteran's mental illness did not cause his heart disorder. Thus, the preponderance of the evidence is also against this portion of the claim. III. Prostate Disorder. As noted above, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(16), 1110 (West 1991). The veteran has reported having prostate cancer. Cancer may be presumed to have been incurred during active military service if it is manifest to a degree of 10 percent or more within the first year following active service. 38 U.S.C.A. §§ 1101, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1994). Service connection may also be granted for a disability which is proximately due to and the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1994). The veteran contends that his current prostate disorder began during service. The service medical records show that he had psychogenic impotence following an appendectomy during service. His genitourinary tract was investigated extensively. In December 1943, his prostate was reported to be normal. It was again found to be normal in February 1944. Records made during the remainder of the veteran's active service and by VA during the years immediately following service show that his genitourinary system was normal without specific reference to the prostate. The summary of the January 1985 VA hospitalization shows the veteran had been seen in December 1985 with complaints of nocturia, frequency, urgency, and incontinence. His prostate was 2+ and smooth. Cystoscopy demonstrated a bulbar urethral stricture which was softly dilated over the course of several days. In April 1986, the veteran was admitted to a VA medical center essentially for the treatment of other disorders. His prostate was nontender without nodules or masses. During a January 1991 VA psychiatric examination, the veteran reported having had surgery for cancer of the prostate. At his July 1991 hearing, he testified that he first had a prostate problem during service, in 1943. He reported that surgery in 1990 disclosed cancerous tumors of the prostate. VA urology clinic notes of September 1993 and June 1994 show that the veteran stated he had prostatic cancer and was radiated in 1987. The cancer appeared to be under control. The veteran had some genitourinary symptoms during service. However, he is not a medical expert so his testimony is not competent evidence to establish that a prostate disorder was manifest during service. See Espiritu, Grottveit. The record made at the time is the best evidence available and it shows that his prostate was normal and his genitourinary symptoms were due to other factors. The preponderance of the evidence demonstrates that no cancer or other prostate disorder was manifested during service or within the first year following service. The first prostate disorder manifestations were found over forty years after the veteran left service. There is no medical opinion linking these to service. Consequently, the record shows no basis for service connection. Service connection may be granted for a disability which is proximately due to and the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1994). The veteran has also contended that his service-connected psychiatric disorder caused his prostate disorder. He has not presented any medical support for this assertion. In August 1994, a VA urologist expressed the medical opinion that there was no correlation between the veteran's prostate problems and his psychiatric disorder. The Board finds this medical opinion to be the best evidence and it establishes that the veteran's prostate disorder is not proximately due to or the result of his service-connected psychiatric disability. ORDER Service connection for a cardiovascular disorder is denied. Service connection for a prostate disorder is denied. A 100 percent rating for chronic anxiety neurosis with conversion reaction is granted as indicated herein, subject to the law and regulations governing the payment of monetary awards. JOAQUIN AGUAYO-PERELES Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.