Citation Nr: 0001121 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 98-11 863A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to an evaluation in excess of 30 percent for post-traumatic stress disorder with a history of anxiety and schizo-affective disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran served on active duty from October 1943 to November 1945. He was a prisoner of war of the German Government from January to April 1945. FINDING OF FACT The veteran's service-connected post-traumatic stress disorder with a history of anxiety and schizo-affective disorder is currently productive of total occupational and social impairment, due to such symptoms as memory loss and an inability to perform the activities of daily living, such that he is unable to obtain or retain gainful employment. CONCLUSION OF LAW A 100 percent evaluation for service-connected post-traumatic stress disorder with a history of anxiety and schizo- affective disorder is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1998); 38 C.F.R. Part 4, Code 9411 (1998). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background On Department of Veterans Affairs (VA) psychiatric examination, conducted as part of a prisoner-of-war protocol examination in December 1986, the veteran was appropriately dressed, though "very anxious" about his memory problems. His affect was anxious, and his mood somewhat depressed. At the time of evaluation, the veteran appeared to have constricted interests concerning his emotional problems. His speech was fairly regulated, spontaneous, and goal-directed. There was no evidence of any loose associations, and no delusional ideation. Nor was there any evidence of religious preoccupation. The veteran occasionally admitted to guilt feelings regarding his not having "accomplished anything" in his life. His memory for recent events was poor, but for remote events, appeared to be fair. Abstractive ability was likewise fair, and he denied any suspiciousness about the people around him. The veteran likewise denied distrustfulness of his peers. He was able to relate his feelings to anyone, though he was "afraid to go back to work." During the course of the evaluation, the veteran had some episodes of crying spells, and continued to have low self-worth. He denied hallucinations, but stated that, in the past, he had heard voices. He denied both suicidal and homicidal ideation, and was fairly oriented in all spheres. He had some insight into his problems, and his judgment was not impoverished. At the time of evaluation, the veteran stated that he was not able to go back to work because of difficulty coping with stress, and "problems with his memory." In a rating decision of March 1987, the Regional Office (RO) granted service connection (and a 30 percent evaluation) for chronic anxiety with schizo-affective disorder, effective from November 3, 1985. On VA psychiatric examination in May 1990, the veteran stated that he was currently receiving prescriptions for psychotropic medication, and saw a doctor on an "as called" or as-needed basis every six weeks to three months. With the exception of some sleep and memory problems, the veteran described no particular difficulties. More specifically, he described himself as having trouble falling asleep, and would, on occasion, have nightmares, causing him to awake. On mental status examination, the veteran tended to ramble, and have loose associations. Eye contact was fair, and he was well oriented. At the time of evaluation, the veteran's recent and remote memory was intact. His affect was characterized as "very flat," and, with the exception of some mildly pressured speech, he showed no particular evidence of anxiety. The veteran's proverb interpretations were quite abstract, and he was not particularly depressed. In the opinion of the examiner, the veteran displayed a "moderate" degree of difficulty. VA outpatient treatment records covering the period from June to August 1997 show treatment during that time for the veteran's psychiatric disability. On VA psychiatric examination in August 1997, it was noted that the veteran's claims folder was available for review. According to the veteran, he found it difficult to fall asleep, and his sleep was "not too good." Reportedly, the veteran woke up "due to nightmares." On mental status examination, the veteran stated that he was once suicidal "many years ago." He spoke with a rather dysthymic mood, and commented that, on those occasions in the past when he would "overindulge" in alcohol, he tended to neglect his family. At the time of evaluation, the veteran was fully oriented to time, person, and place. Calculations performed in his head were totally accurate, and he exhibited the capacity to abstract, both on similarities and on proverbs. There was no evidence of any homicidal ideation, or any history of hallucinations or delusions. The veteran's eye contact was poor, with him often staring at the wall and the ceiling. His responses were often rambling, characterized by excessive detail and sometimes tangential. There was a naïve but sincere quality to his attempt to respond to questions. In the opinion of the examiner, the veteran displayed some signs of both dysthymia and anxiety. His history was consistent with that of a schizo-affective disorder. According to the examiner, the veteran's rambling and tangential conversations were characteristic of that disorder. VA outpatient treatment records dated in September 1997 show continued treatment for the veteran's service-connected psychiatric disability. In September 1997, a VA psychological evaluation was undertaken. At the time of evaluation, the veteran stated that he was presently being followed in individual psychotherapy for chronic insomnia, anxiety and depression, as well as flashbacks and nightmares of his combat and POW experiences, and emotional estrangement from his family. Reportedly, the veteran had been prescribed medication to alleviate his nightmares, but then discontinued such medication due to complaints of oversedation. The diagnostic impression at the time of evaluation was of chronic post- traumatic stress disorder related to intense front-line combat, and the extreme conditions of being a prisoner of war. The veteran's trauma severity was considered catastrophic, and his social and occupational impairment "extremely severe." The veteran's current Global Assessment of Functioning Score was 40, with a score over the past year of between 35 and 40. In the opinion of the examiner, the veteran had been "misdiagnosed" for many years, given that his depression was "secondary to post-traumatic stress disorder." It was recommended that help be given to the veteran in such a way as to take the onus "off of his somehow being defective, crazy, or schizophrenic, as he had been called in the past." It was felt that, like many World War II combat veterans, and, in particular, prisoners of war, the veteran might tend to understate and/or minimize his trauma. This was partly the nature of the disorder (that is, emotional numbing), and partly the result of generational values, specifically, "doing your duty and not complaining." VA outpatient treatment records dated in October 1997 show continued treatment for the veteran's service-connected psychiatric disability. In a rating decision of December 1997, it was noted that, in light of the fact that the veteran was a prisoner of war, and had now been diagnosed with post-traumatic stress disorder, service connection would be conceded for that disability, which would be rated together with the veteran's chronic anxiety/schizo-affective disorder. VA outpatient treatment records covering the period from October 1997 to June 1998 show treatment during that time for the veteran's post-traumatic stress disorder. During the course of a personal hearing in August 1998, the veteran stated that he experienced difficulty with anxiety and nightmares, for which he was currently undergoing therapy (Transcript, pp. 3-6). VA outpatient treatment records covering the period from August to November 1998 show continued treatment during that time for the veteran's psychiatric disability. In mid-August 1998, the veteran was seen for follow up of his diagnosis of anxiety disorder and post-traumatic stress disorder. At the time of evaluation, the veteran reported continued sleep disturbance and nightmares, which, though slightly altered from his original combat experience, still contained a "flavor" of combat. The veteran stated that he felt guilty regarding his inability to work, and was having some difficulty in accepting this fact. It was noted that, given his current age and problems with continued anxiety, working was "out of the question." Still, the veteran was unable to accept this fact, and would distort his capabilities. His inability to concentrate and retain information in long-term memory resembled an age-related illness, but was more likely related to post-traumatic stress disorder. During the course of VA outpatient treatment in October 1998, it was noted that the veteran's current Global Assessment of Functioning Score ranged between 40 and 48, depending on his amount of anxiety and stress. Additionally noted was that the veteran was "not considered employable." In the opinion of the mental health clinic treatment provider, should the veteran attempt to work, he would experience extreme stress and anxiety, which would exacerbate his sleep disturbance, and the "overall condition related to his post-traumatic reactions." Accordingly, it was recommended that the veteran not seek active employment. In correspondence of October 1999, a VA Registered Nurse commented that the veteran's Global Assessment of Functioning Score had fluctuated "between 45 and 50," with an average score "between 45 and 48." During the course of a videoconference hearing before a Member of the Board in October 1999, the veteran complained of increasing difficulty with nightmares and short-term memory, as well as increasing irritability, and a tendency to "get into fights." (Transcript, pp.3-11). Analysis The veteran's claim is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim that is plausible. The Board is also satisfied that all relevant facts have been properly developed and no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The veteran in this case seeks an increased evaluation for his service-connected psychiatric disability, presently characterized as post-traumatic stress disorder with a history of anxiety and schizo-affective disorder. In that regard, disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4 (1998). In evaluating the severity of a particular disability, it is essential to consider its history. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1, 4.2 (1998). However, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). In the present case, following VA psychological evaluation in September 1997, the veteran was described as suffering from "extremely severe" social and occupational impairment as a result of service-connected post-traumatic stress disorder related to "intense front-line combat" and the "extreme conditions" related to being a prisoner of war. His Global Assessment of Functioning Score at that time was 40, with a score over the past year of between 35 and 40. In August 1998, the veteran complained of continued sleep disturbance and nightmares, as well as an inability to concentrate and retain information. As recently as October 1998, it was noted that, should the veteran attempt to work, he would experience "extreme stress and anxiety" which would exacerbate his sleep disturbance and other "overall conditions" related to his post-traumatic stress disorder. His Global Assessment of Functioning Range was said to be between 40 and 48, depending on the amount of anxiety and stress he was experiencing. As a result, the veteran was considered unemployable, and it was "not recommended" that he seek active employment. The Board observes that, in correspondence of October 1999, the veteran's Global Assessment of Functioning Score was reported as fluctuating "between 45 and 50," with an average score "between 45 and 48." Clearly, this places the veteran in a position where his service-connected psychiatric symptomatology is productive of "major impairment" in a number of areas, including work, family relations, judgment, thinking and mood. See Diagnostic and Statistical Manual of Mental Disorders IV (1994). As noted above, the veteran is currently in receipt of a 30 percent evaluation for his service-connected psychiatric disability. In order to warrant an increased, which is to say, 50 percent evaluation, there would, of necessity, need to be demonstrated the presence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: a 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; and difficulty in establishing and maintaining effective work and social relationships. In like manner, a 70 percent evaluation would require demonstrated evidence of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. In order to warrant a 100 percent schedular evaluation, there would, of necessity, need to be demonstrated the presence of 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; and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; and memory loss for names of close relatives, one's own occupation, or own name. 38 C.F.R. Part 4, Code 9411 (effective November 6, 1996). Based on the aforementioned, it is clear that the veteran experiences significant impairment as a result of his service-connected post-traumatic stress disorder. He continues to experience problems with both anxiety and nightmares, affecting not only his memory, but his ability to interact effectively with others. At present, he has been judged incapable of employment. Indeed, it has been recommended by competent mental health professionals that the veteran not seek active employment. Under such circumstances, the Board is of the opinion that the veteran currently suffers from total occupational and social impairment as a result of his service-connected psychiatric disorder. Accordingly, a 100 percent schedular evaluation for that disability is warranted. The benefit of the doubt has been resolved in the veteran's favor. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, Code 9411. ORDER An increased (100 %) evaluation for service-connected post- traumatic stress disorder with a history of anxiety and schizo-affective disorder is granted, subject to those regulations governing the award of monetary benefits. WAYNE M. BRAEUER Member, Board of Veterans' Appeals