Citation Nr: 0006756 Decision Date: 03/13/00 Archive Date: 03/17/00 DOCKET NO. 95-17 495 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to an increase in a 30 percent rating for post-traumatic stress disorder (PTSD). 2. Entitlement to an increase in a 20 percent rating for duodenal ulcer disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Appellant ATTORNEY FOR THE BOARD R. T. Jones, Counsel INTRODUCTION The veteran served on active duty from February 1969 to February 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 1994 decision by the VA RO which denied an increase in a 10 percent rating for service- connected PTSD and denied an increase in a 20 percent rating for service-connected duodenal ulcer disease. In May 1995 the RO granted an increased rating of 30 percent for PTSD, and the veteran continued his appeal for a higher rating. The case was remanded by the Board in January 1998, and was returned to the Board in November 1999. FINDINGS OF FACT 1. The veteran's PTSD results in considerable industrial and social impairment, and it results in occupational and social impairment with reduced reliability and productivity due to various symptoms. 2. The veteran does not have active duodenal ulcer disease or duodenal ulcer symptoms productive of more than moderate disability. CONCLUSIONS OF LAW 1. The criteria for a rating of 50 percent for PTSD have been met. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996), § 4.130, Diagnostic Code 9411 (1999). 2. The criteria for a rating in excess of 20 percent for duodenal ulcer disease have not been met. 38 U.S.C.A. § 1155(West 1991 & Supp. 1999); C.F.R. § 4.114 Diagnostic Code 7305 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The veteran served on active duty in the Army from February 1969 to February 1971. He served in Vietnam and was awarded the Purple Heart Medal. The veteran's February 1971 service separation examination notes that he had upper gastrointestinal bleeding in November 1970. It was reported that he treated himself with medications and still had occasional epigastric burning. On a July 1973 VA examination, an upper gastrointestinal series showed a duodenal ulcer, and the RO granted service connection for it in August 1973. The condition was rated as 20 percent disabling, and that rating has continuously in effect ever since. PTSD was diagnosed on a VA psychiatric examination in October 1985; the RO granted service connection for PTSD later that month. A 10 percent rating was assigned. The veteran was admitted to Lonesome Pine Hospital in February 1994 for gastrointestinal bleeding. He had vomited coffee ground material that was positive for blood. An upper gastrointestinal endoscopy showed antral gastritis, irritation of the duodenal bulb, a hiatal hernia, and distal esophagitis. He was treated with Zantac. The symptoms resolved, and he was discharged one week later with diagnoses of: gastrointestinal bleeding; hiatal hernia, reflux esophagitis, antral gastritis, and duodenitis; degenerative joint disease of the knees and ankles; chemical diabetes; hyperlipidemia; and hyperuricemia, by history. In March 1994 the veteran filed a claim for increased ratings for PTSD and duodenal ulcer disease. A March 1994 gastroenterology consultation by Doug Strickland, M.D., noted that the veteran had a long history of gastrointestinal bleeding, and had been having difficulty with gastroesophageal reflux disease. The recent admission at Lonesome Pine Hospital was described. The veteran reported that he continued to have epigastric discomfort. Examination of the abdomen noted positive bowel sounds and very mild epigastric tenderness. The impressions were; chronic gastroesophageal disease with reported Barrett's changes; history of peptic ulcer disease with a gastrointestinal bleed while on non-steroidal anti- inflammatory agents and is Heliocobacter positive; gouty arthritis; atypical chest pain; PTSD by history; and history of hypertension. Anti-reflux precautions were discussed, and avoiding non-steroidal anti-inflammatory agents was recommended. On a May 1995 VA gastrointestinal examination, it was reported that the veteran had a history of a duodenal ulcer, Barrett's esophagus, and a hiatal hernia. It was noted that he had had multiple episodes of abdominal pain and distress since an episode of gastrointestinal bleeding in service. The veteran reported he felt tired all the time and had a burning pain in the epigastric areas. He said he experienced gastric reflux. Examination showed epigastric tenderness. It was reported that previous endoscopic examinations were consistent with the diagnosis of Barrett's esophagus and erosive gastritis. His weight was 189 pounds with a maximum weight in the last year of 204 pounds. Laboratory studies showed he was not anemic. (Red blood count, hemoglobin, and hematocrit were all within normal limits.) He reported that the last episode of bleeding with vomiting or with a stool was in February 1994. The diagnoses were: Barrett's esophagus; hiatal hernia; and duodenal ulcer. On a May 1995 VA psychiatric examination, the veteran reported he had worked in construction and then in strip mines driving heavy equipment, and had worked for 20 years. He said he had last worked in 1994 because of an episode of gastrointestinal bleeding and severe arthritis in his knees. He reported problems with insomnia and said he was constantly tired because he did not get enough sleep. He reported episodes of disassociation, and said he was recurrently depressed for short periods of time. He claimed difficulty with recent memory and a marked startle response. On reporting of objective findings, it was noted that he appeared chronically dysthymic. His affect was somewhat irritated. His thoughts were logical and goal directed. He had no delusions. He was oriented to time, place, person, and situation. The psychiatric diagnosis was PTSD, moderate to severe. The doctor said that the veteran's Global Assessment of Functioning (GAF) score was approximately 60. In May 1995, the RO increased the PTSD rating to 30 percent. An October 1995 Social Security Administration (SSA) Administrative Law Judge's (ALJ) decision notes the veteran was found disabled for SSA purposes. Conditions noted included gouty arthritis with recurrent attacks of inflammatory synovitis of the knees, ankles, and hands, and PTSD. On a April 1997 VA gastrointestinal examination, it was reported that the veteran had a history of a postprandial lower mid chest burning pains associated with regurgitation of gastric fluids into the mouth and throat, more at night, but also occurring during the day. He said the last episode of gastrointestinal bleeding was in 1994, and at that time was told the cause was esophagitis, gastritis, and a hiatal hernia. After that he quit work. It was reported that esophagogastroduodenoscopy examinations in the 1980s and 1990s had shown Barrett's esophagus, Barrett's ulcers, a hiatal hernia, and gastric erosions, and a duodenal ulcer on some occasions. On other occasions with treatment the ulcers had disappeared, but the Barrett's esophagus and hiatal hernia had persisted. Physical examination showed mild epigastric tenderness, but otherwise normal. The assessments were: gastroesophageal reflux disease with a small sliding hiatal hernia and Barrett's esophagus, and on occasions gastric erosions and a duodenal ulcer. Laboratory studies showed he was not anemic. (Red blood count, hemoglobin, and hematocrit were all within normal limits.) On an April 1997 VA orthopedic examination, the diagnoses were: degenerative joint disease; gouty arthritis, status post joint aspiration of the left knee; and gastroesophageal reflux disease. The examiner said the veteran had extensive degenerative joint disease and gouty arthritis and was not able to take non-steroidal anti-inflammatory medications because of his history of reflux disease. The doctor opined that the veteran was not employable because of his disabilities. On an April 1997 VA psychiatric examination, the veteran reported he had not worked since 1994 due to medical and psychiatric problems. He said he was physically and psychologically distressed. He described intrusive recollections of Vietnam, distressing dreams, flashbacks, diminished interests, hypervigilance, suspiciousness, etc. On reporting of objective findings, it was noted that he appeared alert and oriented. He appeared to be distressed physically with pain and stomach discomfort. He appeared significantly distressed, anxious, and labile. There was no evidence of perceptual disturbances. However, he was clearly hypervigilent, hypersensitive and extremely arousable. The examiner said the veteran's behavior was highly consistent with his subjective symptoms, and that, while there may have been an element of exaggeration, his affect and emotional arousal indicated significant emotional distress and psychological instability regardless of any possible secondary gains that may have been operating. The psychiatric diagnoses were PTSD, chronic, severe; and psychological factors associated with other medical conditions (gastrointestinal disorder as described in his history). The doctor said that the veteran was unable to work because of his medical and psychiatric problems. His GAF score was 40, which was said to represent major impairment in several areas such as work, family relations, mood, judgment, and thinking. The veteran testified at a Board hearing at the RO (i.e., a Travel Board hearing) in September 1997. He said he had flashbacks of mortar attacks in Vietnam and nightmares 3-4 times a week. He said he belonged to the VFW and DAV but did not go to meetings. He said he had 3-4 ulcer flare-ups per year. He submitted a list of medications he took for his various physical and psychiatric conditions. VA outpatient treatment records from 1993 to 1998 show treatment for a variety of medical and psychiatric problems. The records show he was receiving medications for psychiatric complaints, degenerative joint disease, hypertension, and gastroesophageal reflux disease. The veteran underwent an esophagogastroduodenoscopy at a VAMC in February 1998. The antrum, duodenal bulb, and duodenum were all within normal limits. The postoperative diagnoses were a moderate size hiatal hernia and Barrett's-like mucosa extending from 28 cm to the gastroesophageal junction at 37 cm. Biopsies confirmed Barrett's esophagus with chronic inflammation. Earlier studies in recent years showed similar findings. In October 1998 copies of medical records from the SSA were received; these medical records were used as the basis of the October 1995 administrative law judge decision. The records include an August 1995 evaluation by Edward Latham, Ph.D., which noted that the veteran stopped working in February 1994 because of gastrointestinal bleeding. Mental status examination noted that the veteran displayed a fretful and depressed mood, and he had an affect appropriate to his thought content. He reported frequent depressed periods where he had to go off by himself. The impression was PTSD, and the doctor said the veteran appeared to be able to understand and follow simple instructions. His attention/concentration were judged to be sufficient for simple tasks. He had a moderate impairment of ability to relate interpersonally and marked impairment in his ability to handle everyday stressors. The SSA records noted that the veteran was found to be disabled from February 1994 with a primary diagnosis of rheumatoid and other inflammatory arthritis and a secondary diagnosis of affective disorders. A December 1998 VA psychiatric examination, the veteran reported he had not worked since 1994 due to arthritis and psychiatric problems. He reported he lived in his own home, with his wife and children, and maintained contact with other relatives. He related he was becoming more isolated and frequently spent time in the mountains. He complained of constant depression, chronic insomnia, increasing frustration, and constant intrusive recollections and flashbacks. Objective findings were reported as showing that he was alert and oriented in 4 spheres. His speech was slow, but logical and coherent. There was no evidence of a thought disorder. His affect was flat with little reactivity. He acknowledged loss of appetite and poor motivation and energy level. He said he had 3-4 episodes of tearfulness a week. He reported nervousness, a pounding heart, and estrangement from formerly close relationships. He said he had anxiety attacks 2 times a week. There was moderate to severe memory impairment, moderate impairment of concentration, and fair insight. The examiner reported that psychological tests supported a clinical picture of significant distress. The diagnoses were PTSD, chronic, severe; major depressive disorder, recurrent without full episode recovery; and panic disorder without agoraphobia. The doctor said the veteran's GAF score was 55 with a high score of 58 in the last year. The examiner stated that based on the present assessment, records reviewed, and results of psychological testing, it appeared that the veteran continued to suffer from a disabling depression on almost a constant basis as well as frequent panic attacks. The effects of these affective and anxiety disorders were manifested not only in his subjective distress, but also in significant impairment of social functioning. His intolerance of noise and activity and his need for solitude was distancing him from his family. The veteran was becoming uncomfortable with social contact and growing more isolated. Impairment of social functioning was estimated to be moderate to severe. In addition to his physical problems (e.g., arthritis and arm weakness), his significant depression and PTSD symptomatology rendered him unemployable. The doctor said that given the progressively worsening nature of the veteran's symptoms, the prognosis for significant improvement was poor. On a December 1998 VA gastrointestinal examination, it was noted that the veteran's current complaints were heartburn, regurgitation of sour material, and pressure in the chest and upper epigastrium. A review of the veteran's medical confirmed that he had a firm diagnosis of Barrett's esophagus with specialized columnar epithelium being confirmed by endoscopic examinations and biopsies. It was noted that he was observed to have a scar in the duodenal bulb consistent with past ulcer disease, but had not had an active ulcer in the last few years. A November 1998 upper gastrointestinal X-ray study for this examination showed a normal stomach and duodenum, with no evidence of peptic disease. On physical examination in December 1998, abdominal examination was unremarkable except for voluntary guarding on palpation. It was noted that he was moody and somewhat anxious. There was no anemia, jaundice, or cyanosis. The diagnoses included gastroesophageal reflux disease and Barrett's esophagus. The examiner commented that there was no active duodenal ulcer now nor during endoscopies performed over the last several years. II. Analysis The veteran's claims for an increase in a 30 percent rating for PTSD and an increase in a 20 percent rating for duodenal ulcer disease are well grounded, meaning not inherently implausible. All relevant facts have been properly developed and, therefore, the VA's duty to assist the veteran has been satisfied. 38 U.S.C.A. § 5107(a). VA disability evaluations are determined by a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A. PTSD During the course of the veteran's appeal, the regulations pertaining to rating psychiatric disabilities were revised. The veteran's PTSD was initially evaluated under 38 C.F.R. § 4.132, Code 9411, as in effect prior to November 7, 1996. The old rating criteria provide that a 30 percent rating is assigned when there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people, and the psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. A 50 percent rating is assigned when the ability to maintain effective or favorable relationships with people is considerably impaired, and by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent rating is assigned when the ability to established and maintain effective or favorable relationships with people is severely impaired, and the psychoneurotic symptoms are of such severity that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation requires that attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community; 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; demonstrably unable to obtain or retain employment. See Johnson v. Brown, 7 Vet. App. 95 (1994) (holding that the criteria in 38 C.F.R. § 4.132 for a 100 percent rating are each independent bases for granting a 100 percent rating). On November 7, 1996, the rating criteria for PTSD were revised and are now found in 38 C.F.R. § 4.130, Code 9411. The new rating criteria provide that a 30 percent rating is assigned for occupational and social impairment with 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is to be assigned for 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 to be assigned for 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation requires 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. As the veteran's claim for an increased rating for PTSD was pending when the regulations pertaining to psychiatric disabilities were revised, he is entitled to the version of the law most favorable to him. Karnas v. Derwinski, 1 Vet. App. 308 (1990). Here, either the old or new rating criteria may apply, whichever are most favorable to the veteran. The May 1995 VA psychiatric examination led to a diagnosis of moderate to severe PTSD, and the GAF score was 60, which represents moderate occupational and social impairment. The April 1997 VA examination led to a diagnosis of severe PTSD, and the GAF score was 40, which represents major impairment. The December 1998 VA examination included diagnoses of severe PTSD, and the GAF score was 55, which represents moderate impairment. Similar findings are in the treatment records. The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. 38 C.F.R. § 4.130 (1996); 38 C.F.R. § 4.126 (1999); VAOPGCPREC 10-95. As to the veteran's industrial impairment, the evidence shows that he has not worked in several years, but such is primarily due to physical conditions including arthritis, not because of his PTSD. He asserts that he has become increasingly isolated, yet the file shows he maintains some social contacts. Moreover, his social impairment is significant only as it affects his industrial impairment. 38 C.F.R. § 4.129 (1996); 38 C.F.R. § 4.126 (1999). Even though the veteran's physical conditions predominate in his overall industrial impairment, the evidence as a whole depicts some worsening of his PTSD. The PTSD symptoms described at the VA examinations suggest that, even if the veteran were physically able to work, his PTSD would be productive of considerable industrial and social impairment (old criteria for a 50 percent rating) and productive of occupational and social impairment with reduced reliability and productivity due to various symptoms (new criteria for a 50 percent rating). With application of the benefit-of-the- doubt rule (38 U.S.C.A. § 5107(b)), the Board finds that the veteran's PTSD warrants a higher rating of 50 percent. The evidence clearly shows the requirements for a rating higher than 50 percent are not met under either the old or new rating criteria. B. Duodenal ulcer A moderate duodenal ulcer, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations, warrants a 20 percent evaluation. Moderately severe duodenal ulcer, which is less than severe but with impairment of health manifested by anemia and weight loss, or with recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year, warrants a 40 percent evaluation. Severe duodenal ulcer with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health, warrants a 60 percent evaluation. 38 C.F.R. 4.114, Diagnostic Code 7305 (1999). The recent VA examinations and endoscopic examinations show that the veteran has not had an active duodenal ulcer for several years. He has had gastrointestinal symptoms that have been shown to be related to gastroesophageal reflux disease, a hiatal hernia, and Barrett's esophagus; but service connection is not in effect for these conditions. Without any current symptoms from a duodenal ulcer, let alone medical evidence of moderately severe duodenal ulcer symptoms as required for a higher rating, an increased rating is not warranted. It appears the veteran's duodenal ulcer disease does not meet the requirements for the current 20 percent rating, although such rating is protected from reduction. 38 U.S.C.A. § 110. The Board concludes that the preponderance of the evidence is against a rating greater than 20 percent for duodenal ulcer disease. Thus, the benefit-of-the-doubt rule does not apply, and the claim for a higher rating must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App 49 (1990). ORDER An increased rating, to 50 percent, for PTSD is granted. An increased rating for duodenal ulcer disease is denied. L. W. TOBIN Member, Board of Veterans' Appeals