BVA9500644 DOCKET NO. 93-05 352 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an increased rating for service-connected post traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. 2. Entitlement to service connection for hypertension with hypertensive cardiovascular disease, secondary to service- connected PTSD. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES Appellant; G.S. ATTORNEY FOR THE BOARD M. J. Bohanan, Associate Counsel INTRODUCTION The appellant served on active duty from March 1948 to October 1953 and was interned as a prisoner of war from July 1950 to August 1953. This appeal arises from an August 1991, Department of Veterans Affairs Regional Office, New Orleans, Louisiana (VARO) rating decision which granted the appellant an increased rating for his service-connected PTSD, from 10 to 30 percent disabling, and denied service connection for hypertension with hypertensive cardiovascular disease. CONTENTIONS OF APPELLANT ON APPEAL In essence, the appellant contends that manifestations of his service-connected PTSD, currently evaluated as 30 percent disabling, are of sufficient severity to warrant an increased rating. He also contends that he is entitled to service connection for hypertension with hypertensive cardiovascular disease which he claims is etiologcially related to his service- connected PTSD. 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. For the following reasons and bases, it is the decision of the Board that the evidence does not support an increased rating for the appellant's service-connected PTSD, and that service connection is not warranted for hypertension with hypertensive cardiovascular disease. FINDINGS OF FACT 1. The appellant served on active duty from March 1948 to October 1953 and was interned as a prisoner of war from July 1950 to August 1953. 2. Current manifestations of the appellant's service-connected PTSD, include periods of violent temperament and anxiety, intruding thoughts and sleep disturbances. 3. No evidence has been submitted which leads to the conclusion that any medical relationship exists between the appellant's service-connected PTSD and his claimed hypertension with hypertensive cardiovascular disease. CONCLUSIONS OF LAW 1. The manifestations of the appellant's service-connected PTSD are no more than 30 percent disabling. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 4.132, Diagnostic Codes 9411 (1993). 2. The appellant's hypertension with hypertensive cardiovascular disease was not incurred in or aggravated by military service, and is not proximately due to or the result of a service connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this appeal, the appellant is seeking an increased rating for his service-connected PTSD, currently evaluated as 30 percent disabling, and service-connection for hypertension with hypertensive cardiovascular disease, claimed as secondary to his service-connected PTSD. Initially, the Board finds that the appellant has satisfied his statutory burden of submitting evidence which is sufficient to justify a belief that his claim is "well-grounded." 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet.App. 78 (1990). It is also clear that the appellant's claim has been adequately developed for appellate review purposes by VARO, and the Board may therefore proceed to disposition of the matter. In evaluating the appellant's request for an increased rating, the Board considers all of the medical evidence of record, including the appellant's relevant medical history. Peyton v. Derwinski, 1 Vet.App. 282 at 287 (1991). Disability evaluations are determined by the application of a schedule of ratings based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1993). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 (1993) 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 (1993) requires that medical reports be interpreted in light of the whole recorded history. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). The schedular criteria for PTSD call for a 30 percent disability rating for definite impairment in the ability to establish or maintain effective and wholesome relationships with people; a 50 percent disability rating is warranted for PTSD which results in considerable industrial impairment. A 70 percent disability rating is warranted for PTSD which results in severe impairment of social and industrial adaptability. A 100 percent disability rating is warranted if PTSD results in totally incapacitating psychoneurotic symptoms, bordering on gross repudiation of reality with disturbed thought or behavioral processes, resulting in profound retreat from mature behavior. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 4.132, Diagnostic Code 9411 (1993). The terms "considerable" and "severe" are not defined in VA regulations. Rather than applying an inflexible formula, it is incumbent upon the Board to arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6 (1993). It should also be noted that use of terminology such as "considerable", and "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (1993). In a precedent opinion, dated November 9, 1993, the General Counsel of the VA concluded that "definite" is to be construed as "distinct, unambiguous, and moderately large in degree." It represents a degree of social and industrial inadaptability that is "more than moderate but less than rather large." O.G.C. Prec. 9-93 (Nov. 9, 1993). The VA, including the Board, is bound by this interpretation of the term "definite." 38 U.S.C.A. § 7104(c) (West 1991). With these considerations in mind, the Board will address the merits of the claim at issue. The appellant is also seeking service connection for hypertension with hypertensive cardiovascular disease. Under pertinent law and VA regulations, service connection may be granted if symptomatology attributable to hypertension with hypertensive cardiovascular disease was incurred during service or is clinically manifested within one year thereafter, in this case by October 1954, or it is found to be proximately caused by or the result of the appellant's service-connected PTSD. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.303, 3.306, 3.309, 3.310 (1993). Service connection may also be granted if a disability is found to be proximately due to or is the result of a service-connected disability or disabilities. 38 C.F.R. § 3.310 (1993). It is not necessary to have a diagnosis of a particular disability during service, but it is necessary to have manifestations sufficient to establish that a disability was present. 38 C.F.R. § 3.303(d) (1993). Before discussing the appellant's claim, the Board believes that an overview of the appellant's medical history is in order. Medical history A September 1953 military psychiatric examination reported no disease. At the time, the appellant's blood pressure reading was 120/ 70. His October 1953 military separation examination was also negative for any psychiatric disorders, and no heart or circulatory abnormalities were indicated. A VA examination was conducted in February 1955. The appellant's blood pressure reading was 128/68 and he had normal peripheral circulation. No psychiatric disorders were observed. A January 1960 VA examination reported a blood pressure reading of 134/72 and noted no psychiatric abnormalities. VA examinations were conducted in January and February 1985. A February 1985 VA psychiatric evaluation reported that the appellant denied any episodes of depression. He claimed to have dizzy spells which he attributed to his "nerves." He also claimed that he had hypertension and suffered from "blackout spells". He denied any prior psychiatric treatment or evaluation. He reported nightmares just after service. However, he claimed he had not had these for many years. The examiner's impression was generalized anxiety disorder. A psychological evaluation reported that he was mildly depressed and moderately anxious much of the time, but not severely disturbed from an emotional standpoint. The examiner observed that the appellant exhibited most of the residuals of PTSD, and remained troubled by intruding thoughts, sleep disturbance, emotional numbing and irritability. There was no indication of a basic integrative defect or psychotic process. The examiner's impression was chronic PTSD. The appellant's blood pressure readings were 200/130 in all positions. Blood pressure readings taken at the hypertension clinic were 164/84, 162/72, 154/78 and 146/82. However, after he was taken to the nurses station to be checked again, he had a blood pressure reading of 180/110. A March 1991 VA psychological evaluation reported that the appellant exhibited chronic, severe, and debilitating symptoms of PTSD, including extreme sadness, personal dissatisfaction, marked guilt, self-blame, frequent crying, easy irritation, indecisiveness and fatigue, complicated by additional anxiety and depression phenomena. The examiner's impression was chronic, severe PTSD. A February 1991 POW protocol examination reported that the appellant presented with, among other physical disorders, systolic hypertension and hypertensive heart disease for which he was taking medication. A psychiatric evaluation reported that the appellant was working approximately 60 hours per week as the manager of a small general store, but felt "overwhelmed" at times. He claimed to enjoy taking long walks, fishing or hunting, but complained of difficulty handling stress, and that he tried to avoid stressful situations. He reported that he suffered from nightmares and sleepwalking from "time-to-time", and had markedly disturbed memory. However, he did not complain of crying spells, decreased appetite, weight loss, or insomnia. The examiner's impression was chronic PTSD with evidence of cognitive decline and dementia, from which he was moderately incapacitated. Private medical treatment records dated from February 1971 to May 1989 reported that the appellant was treated for various physical disorders including hypertension on numerous occasions. At his April 1992 hearing on appeal, the appellant testified regarding his prisoner of war experiences. He claimed that, although he suffered brutality during his capture and lost weight, he was in "pretty fair medical shape" at the time of his release. He claimed that he suffered from nightmares; had periodic violent episodes; was "easily irritated"; would get depressed; and did not socialize often. He testified that the first time he was told that he had hypertension was in the early 1960s. He believed that his hypertension was "related" to his PTSD, because he thought that the more nervous he got, the higher his blood pressure would go. He reported that, since he sold his trucks in 1982, he had "just been batching around" and that he worked until January 1992. The appellant's wife, G. S., corroborated that the appellant had a violent temper at times and that he had taken medication for hypertension "for years." An April 1991 VA examination reported that the appellant complained of exaggerated pains in his chest with work or exertion. His blood pressure reading was 184/78. The examiner noted a history of hypertension and that the appellant was taking medication. 1. Entitlement to an increased rating for service-connected post traumatic stress disorder, currently evaluated as 30 percent disabling. After evaluating the evidence, the Board has concluded that the appellant suffers from PTSD symptomatology which produces definite social impairment. We have noted, in particular, his descriptions of his PTSD symptoms, as well as his wife's corroborations of violent temperament. The Board believes that such symptomatology justifies the assignment of a 30 percent disability rating 38 C.F.R. § 4.2 Diagnostic Code 9411 (1993). However, in our opinion, the appellant's PTSD symptoms have not resulted in considerable industrial impairment as called for in the Schedule for Rating Disabilities for a 50 percent disability evaluation. The appellant's behavior, as evidenced by his hearing testimony and by the medical reports of record, includes the ability to maintain relationships with family members and to function in an employment atmosphere. The history he gives is accurate. Moreover, it appears from the medical records described above, that not all of the appellant's psychiatric problems are due to his service-connected PTSD. A generalized anxiety disorder and depression, neither of which is service connected, have contributed to his social and industrial impairment. Accordingly a 50 percent disability rating may not be assigned based on the diagnostic code criteria. 2. Entitlement to service connection for hypertension with hypertensive cardiovascular disease. The Board finds that the objective medical evidence does not substantiate that the appellant's hypertension with hypertensive cardiovascular disease was incurred during military service, or is related to his currently diagnosed PTSD. In so finding, the Board places emphasis on his service medical records, which were negative for any heart or circulatory disorders; his February 1955 VA examination which was also negative for any indication of hypertension or circulatory disorders; and the lack medical evidence of regular or continuous treatment for hypertension from October 1953 to February 1971, approximately twenty years after service. The objective medical evidence also does not attribute the onset of the appellant's hypertension problems to service and does not make any reference to a relationship between his hypertension with hypertensive cardiovascular disease to his service-connected PTSD. The Board has considered the written statements of the appellant claiming an etiological relationship between his service-connected PTSD and his currently diagnosed hypertension with hypertensive cardiovascular disease. However, the Board finds that those statements have less probative value than the objective medical records during and after service. As the appellant is a layman, his contentions are not probative as he is not competent to provide a medical opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As mentioned, service medical records are devoid of any reference to hypertension with hypertensive cardiovascular disease. Likewise, from the time of the appellant's discharge from service in October 1953 to February 1971, there are no medical records to indicate a diagnosis of hypertension. Further, although the appellant claimed to have had hypertension for years prior to February 1971, there are no records pertaining to complaints or treatment concerning PTSD symptomatology until February 1985. The medical record does not substantiate a claim that the appellant either suffered from hypertension with hypertensive cardiovascular disease during service or that he has experienced a continuity of symptomatology so as to establish chronicity since his discharge. "[W]hen the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim." 38 C.F.R. § 3.303(b) (1993). There is also no medical evidence to indicate a relationship between the appellant's PTSD and his hypertension with hypertensive cardiovascular disease. Therefore, it is the opinion of the Board that the appellant's hypertension with hypertensive cardiovascular disease is unrelated to his military service, that it is not proximately due to or the result of his service-connected PTSD symptomatology, and that entitlement to service connection for hypertension with hypertensive cardiovascular disease is not warranted. ORDER An increased disability rating for the appellant's service- connected post traumatic stress disorder is denied. Service connection for hypertension with hypertensive cardiovascular disease is denied. C. P. RUSSELL 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.