Citation Nr: 0001164 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 97-35 071 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently evaluated at 50 percent. 2. Entitlement to service connection for coronary artery disease (CAD) as secondary to the service-connected PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Edward Walls, Associate Counsel INTRODUCTION The veteran served on active duty from August 1942 to July 1945. His appeal comes before the Board of Veterans' Appeals (Board) from a June 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. 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 PTSD causes total occupational and social impairment. 3. The veteran's CAD is aggravated by his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 100 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411 (1999). 2. Entitlement to service connection for CAD as secondary to the service-connected PTSD is warranted. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran and his representative contend that, based on the symptomatology presented during a July 1998 VA mental disorders examination, a 100 percent evaluation for PTSD is warranted. The representative has noted that the VA examiner scored the veteran's Global Assessment of Functioning (GAF) as 50. The veteran has also contended that his CAD should be service connected as secondary to his PTSD because it caused the heart disease or aggravated its symptoms, especially angina. The Board recognizes the veteran's contentions; however, the preliminary issue is whether he has submitted well-grounded claims, and if so, whether the VA has properly assisted him in the development of his claims. Considering the veteran's contentions, the Board finds his claims plausible and capable of substantiation and therefore well grounded within the meaning of 38 C.F.R. § 5107(a) (West 1991). See Caffrey v. Brown, 6 Vet.App. 337, 381 (1994); Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992). The Board is also satisfied that the RO has developed all relevant evidence necessary for an equitable disposition of this appeal. Therefore, no further assistance to the veteran is required. In accordance with 38 C.F.R. §§ 4.1, 4.2 (1999) and Schafrath v. Derwinski, 1 Vet.App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's service-connected disabilities. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. The Board concludes that this case presents no evidentiary considerations, except as noted below, which warrant an exposition of the remote clinical history and findings pertaining to the disabilities at issue. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disabilities adversely affect his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Although regulations require that a disability be viewed in relation to its whole recorded history, see 38 C.F.R. §§ 4.1, 4.2, 4.41, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). 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. 1. Post-traumatic stress disorder The RO service connected the veteran's psychiatric disorder in July 1948, and it was re-characterized as PTSD in January 1989. The veteran is currently evaluated as 50 percent disabled for PTSD. A 50 percent disability evaluation is warranted for PTSD causing 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability evaluation is warranted for PTSD causing 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); or the inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for PTSD causing 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; or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). The veteran has been evaluated by the VA numerous times since World War II. The RO increased the veteran's disability evaluation from 30 percent to 50 percent based on the most recent examination in July 1998. During that examination, the veteran reported that he had been becoming increasingly isolated and he was having daily intrusive thoughts. He reported crying spells about two times per week and flashbacks about once per month during which he had a very vivid recollection about a particular war experience. He told the examiner that his flashbacks had increased in both intensity and duration. On mental status examination, his voice was tremulous when describing war incidents and at one point he started to cry. He appeared to be having intrusive thoughts of the war experiences. He showed no signs of hallucinations or delusions, and there was no evidence of psychosis. However, the examiner stated that the veteran's concentration appeared to be poor. Recent and remote memory were generally intact. The veteran's sleep appeared to be impaired; he had initial insomnia and then would wake up after three or four hours with thoughts of both current and war-related situations. He felt fatigued much of the time. The examiner stated that the veteran at that time met all the criteria for continuation of a PTSD diagnosis, including recurrent intrusive thoughts, distressing dreams, flashbacks. The examiner also stated that the veteran tended to avoid thoughts or feelings associated with trauma, and he was showing a marked diminished interest in activities and a feeling of estrangement from others. The examiner reported that the veteran's symptoms had worsened over the past few years, and he assessed the veteran's GAF at 50. Based on the veteran's GAF of 50 and the symptomatology presented during the mental disorders examination in July 1998, the Board concludes that the medical evidence reflects that the veteran's PTSD causes total occupational and social impairment. The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV), indicates that a GAF score of 41 to 50 reflects serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). As noted above, the examiner in July 1998 indicated that the veteran had recurrent intrusive thoughts and that he was suffering from flashbacks and nightmares. He also stated that the veteran's symptomatology had deteriorated, and that he was becoming more isolated and estranged from others. The Board is satisfied that this symptomatology, in conjunction with the GAF score of 50, reflects that the veteran's PTSD causes total occupational and social impairment as envisioned by the rating schedule; thus, a 100 percent evaluation for PTSD is warranted. 2. Coronary artery disease Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Additionally, a disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). When aggravation of a disease or injury for which service connection has not been granted is proximately due to, or the result of, a service- connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Although there is no competent medical evidence in the claims file that the veteran's service-connected PTSD caused his heart disease, several medical opinions suggest that his CAD symptomatology may be aggravated by his PTSD, specifically his angina. A November 1996 letter from Craig K. Reiss, M.D., reflects that the veteran was seen by his office first in October 1993 and he was complaining of exertional angina at that time. A cardiac catheterization revealed a dominant right coronary artery which was totally occluded. Dr. Reiss reported that the veteran's cardiac risk factors included a distant history of cigarette smoking, which he quit 25 years ago, and a history of elevated cholesterol. He also indicated that he had been asked to discuss the issue of PTSD and its relationship to the veteran's CAD. He stated that "stress has been shown to have some role in coronary artery disease. Certainly if a patient is having panic attacks and/or is under extreme stress angina can occur." A second letter by Dr. Reiss dated June 1998 essentially reiterated these statements. He added, however, that stress has also been linked to coronary events. Therefore, Dr. Reiss felt that the PTSD could be contributing to part of the veteran's ongoing cardiac symptoms. A February 1999 VA examination report reflects that the veteran's cardiac risk factors included a 30-year history of smoking cigarettes, a 20- or 30- year history of heavy alcohol intake, and hypercholesterolemia. In the examiner's opinion, it was more likely than not that the predominant cause of the veteran's CAD was his plaque formation causing blockage in the vessels of his heart. Moreover, the examiner reported that the veteran's risk factors were more likely than not the majority of the contributing factors, rather than his PTSD. A VA examination report dated April 1999 corroborates the February 1999 opinion. According to this report, angina is a symptom of CAD and occurs when myocardial oxygen demand exceeds supply. Angina can be precipitated by exercise, spasm of the coronary arteries, and/or physical and mental stress. The examiner reported that in the presence of CAD, mental stress associated with PTSD could exacerbate angina. It was his opinion that the veteran's CAD was not caused by PTSD, but rather by the presence of clearly defined coronary risk factors. However, the examiner indicated that the veteran's PTSD was probably exacerbating the symptoms of CAD, specifically the symptom of angina. In light of the private and the VA opinions, the Board concludes that the evidence reflects that the veteran's CAD is aggravated by his service-connected PTSD. The United States Court of Appeals for Veterans Claims (Court) has held that when aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Under Allen and 38 C.F.R. § 3.310(a), such aggravation provides a basis for the grant of service connection; thus, service connection is warranted for the veteran's CAD. ORDER Subject to the regulations governing the payment of monetary benefits, entitlement to a 100 percent evaluation for PTSD is granted. Entitlement to service connection for CAD as secondary to the service-connected PTSD is granted. WARREN W. RICE, JR. Member, Board of Veterans' Appeals