Citation Nr: 0001428 Decision Date: 01/18/00 Archive Date: 01/27/00 DOCKET NO. 98-04 304 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to an increased rating for Post-traumatic Stress Disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. L. Wright, Associate Counsel INTRODUCTION The veteran served on active duty from October 1966 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) from a June 1997 rating decision by the Baltimore, Maryland, Regional Office (RO) of the Department of Veterans Affairs (VA) which denied a May 1997 request for an increased evaluation for the veteran's service-connected PTSD. A Notice of Disagreement (NOD) was received in July 1997, a Statement of the Case was issued in August 1997, and a substantive appeal was received in March 1998. The Board notes that in July 1997 correspondence, the veteran asserted that his PTSD symptomatology was of such severity that it precluded him from obtaining and maintaining gainful employment. The issue of entitlement to a total disability rated due to individual unemployability is hereby referred to the RO. FINDING OF FACT The veteran's PTSD is manifested by anxiety, insomnia, nightmares, distressing recollections and decrease in work efficiency more nearly approximating occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for a 50 percent evaluation (but no higher) for the veteran's service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.7, Diagnostic Code 9411 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION The veteran contends that his 30 percent rating for PTSD does not adequately portray the severity of his symptomatology. In particular he asserts that he suffers from increased nightmares, night sweats, irritability and the inability to interact in interpersonal relationships. A veteran who submits a claim for benefits under laws administered by VA shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. See 38 U.S.C.A. § 5107(a). A mere allegation that a service- connected disability has become more severe is sufficient to establish a well-grounded claim for an increased rating. See Caffree v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Accordingly, the Board finds that the veteran's claim for an increased evaluation is well grounded. Once a veteran has presented a well-grounded claim, VA has a duty to assist him in developing facts that are pertinent to the claim. See 38 U.S.C.A. § 5107(a). The Board notes that VA medical records from March and April 1997 are of record and appear to be adequate to allow for equitable review of the veteran's claim. Accordingly, the Board finds that the duty to assist the veteran has been met. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). For comparison purposes, the Board observes that VA examination in January 1997 showed the veteran to be well- groomed, cooperative and with good eye contact. Speech was normal and goal-directed. He was alert, denied homicidal or suicidal thoughts and appeared cognitively intact. He did appear somewhat anxious, but his affect appeared normal in range. The pertinent diagnosis was PTSD, very mild. The veteran was hospitalized in VA facilities in March 1997 and again in April 1997. In March, the veteran was admitted to the VA hospital for 5 days. His discharge diagnosis was chronic PTSD, major depressive disorder, and alcohol abuse by history. The physician assigned a Global Assessment of Functioning Score of 55. The Global Assessment of Functioning (GAF) scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) [hereinafter DSM-IV]. A 51-60 score indicates "moderate symptoms . . . OR any moderate difficulty in social, occupational, or school functioning . . . ." During the March 1997 hospitalization, the veteran's mental status was evaluated and the veteran was alert, cooperative and mild mannered. He was also anxious, talkative and well kept, with no acute distress. He had good eye contact and rapport with the interviewer. The veteran became visually anxious and tearful when describing the death of a friend in Vietnam. Speech was clear with a normal rate of volume. The veteran's affect was mostly anxious, as was mood. Thought processes showed no looseness of association or flight of ideas or thought blocking. Thought content was mostly preoccupied with panic attacks and insomnia. There was no evidence of paranoid delusions or ideas of reference. He denied suicidal or homicidal ideas or plans. There were no bizarre thoughts and perceptual disturbances such as hallucinations or illusions were denied. The veteran was oriented. Three objects were recalled at five minutes and there was a good capacity for abstraction. Intelligence seemed in the average range. Judgment and insight were okay. Test results during the psychological evaluation showed that his prominent symptoms include depressed mood, moderate anxiety, irritability and feelings of despondency as well as numerous somatic complaints. The veteran experienced a considerable number of symptoms of PTSD that could in large part account for his personal and interpersonal problems. The physician states that the hallmark PTSD symptoms of reexperiencing events via nightmares, distressing recollections or physiological reactions and exposure to reminders of war have impaired his ability to function socially and work as efficiently as he was accustomed to in the past. The veteran reported two dissociative flashback episodes within the last month and other significant dissociative tendencies secondary to PTSD. He continued to experience considerable avoidance symptoms such as social avoidance, feelings of detachment and a moderately restricted range of affect. He reported no amnesia due to the stressors, but did note a significant loss of formerly enjoyed activities. The veteran's hyperarousal symptoms included marked sleep disturbances, moderate to severe startle response, potentially severe outbursts of anger and marked hypervigilance. The examiner further noted that, in light of the veteran's use of alcohol in the past to self medicate PTSD symptoms and his considerable period of sobriety, the overall severe impact on his social and occupational function could be more directly attributable to his PTSD rather than residual effects of alcohol abuse. In April 1997, the veteran was again hospitalized and diagnosed with chronic PTSD, major depressive disorder and alcohol abuse by history. He was again assigned a GAF score of 55. The physician referred to the March 1997 hospitalization for medical history and mental status examination, as evidently there were no changes in either. The veteran was discharged on medication to be followed on an outpatient basis. The veteran's PTSD has been evaluated as 30 percent disabling pursuant to the criteria set out in 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted where the disorder is manifested by occupational and social impairment with an 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; and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted where the disorder is manifested by 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. A 70 percent rating is warranted where the disorder is manifested by 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 that is 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. Viewing the evidence from a longitudinal perspective, it appears that the veteran's PTSD symptomatology has increased in severity since the January 1997 VA examination. The March and April 1997 VA hospital reports document such an increase in severity. However, while it appears that there has been an increase in severity, it is not entirely clear that the criteria for the next higher rating of 50 percent have been met. In this regard, while the veteran clearly suffers from anxiety and sleep impairment, these symptoms are contemplated by the current 30 percent evaluation. There does not appear to be significant problems with short or long term memory, and there is no clear evidence of impairment of judgment. On the other hand, the March and April hospital reports do document almost daily intrusive recollections and nightmares several times a week. A moderate to severe startle response was noted as was potentially severe outbursts of anger. While not determinative in itself, the Board notes that the March 1997 hospital report refers to an overall severe impact on the veteran's social and occupational function. After comparing the several VA medical records, the Board believes that a reasonable doubt exists as to whether or not the veteran's disability picture more nearly approximates the criteria for the next higher rating of 50 percent. By statute, all reasonable doubt must be resolved in the veteran's favor. 38 U.S.C.A. § 5107(b). Accordingly, the Board concludes that a 50 percent rating is warranted. However, it is readily clear that the criteria for a 70 percent rating have not been met. There is no evidence of suicidal ideation; obsessional rituals, speech that is intermittently illogical, obscure, or irrelevant, near- continuous panic or depression, spatial disorientation, or neglect of personal appearance and hygiene. While some outbursts of anger have been reported, the overall PTSD symptomatology does not meet the diagnostic criteria for the next higher rating of 70 percent. Further, there is no indication that an extraschedular evaluation is merited in this matter. The potential application of various provisions of Title 38 of the Code of Federal Regulations have also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). The Board finds the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) have not been met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a 50 percent rating for PTSD is warranted. To this extent, the appeal is granted. ALAN S. PEEVY Member, Board of Veterans' Appeals