BVA9506107 DOCKET NO. 91-36 523 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to restoration of a 50 percent rating for paranoid- type schizophrenia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Connolly, Associate Counsel INTRODUCTION The veteran had active service from May 1969 until October 1971. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision of January 1991, proposing to reduce the evaluation for schizophrenia from 50 percent to 30 percent from the Department of Veterans Affairs (VA), New Orleans, Louisiana, Regional Office (RO). The notice of disagreement was received in February 1991. The veteran testified at a personal hearing at the RO in March 1991. The hearing officer's decision was rendered in March 1991 in which the hearing officer affirmed the proposal to reduce the veteran's rating form 50 percent to 30 percent. In an April 1991 rating action the evaluation was reduced to 30 percent. The statement of the case was sent to the veteran in April 1991. The substantive appeal was received in April 1991. In an April 1992 decision, the case was remanded for further development. The case is now ready for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The veteran and his representative contend that the veteran's prior 50 percent rating for service-connected paranoid-type schizophrenia should be restored. The representative asserts that the veteran has never been assigned a rating below 50 percent until the recent reduction. The representative further asserts that the veteran's industrial impairment was not considered by the RO and contends that the veteran is severely industrially impaired. The veteran asserts that he still experienced auditory hallucinations and paranoia. He contends that he has been unable to maintain employment due to his inability to concentrate or just because he began "feeling bad." He further related that he is taking medication to control his psychiatric disorder. 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. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the veteran is entitled to a restoration of the prior 50 percent rating for his service-connected schizophrenia, paranoid type. FINDING OF FACT In view of the veteran's long history of considerable social and industrial impairment due to his service-connected schizophrenia, the recent medical evidence does not make it reasonably certain that the recent improvement in his psychiatric disorder will be maintained by the veteran under the ordinary conditions of his lifestyle. CONCLUSION OF LAW A restoration of the veteran's prior 50 percent rating for schizophrenia, paranoid type, is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 3.344 , Diagnostic Code 9203 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim as to this issue is well grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). That is, the Board finds that he has presented a plausible claim. The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107 (West 1991). A review of the veteran's service medical records does not reveal any findings relative to a psychiatric disorder. However, within several months of discharge, the veteran was hospitalized at a VA facility for complaints of auditory hallucinations, suicidal ideation, and feelings of depersonalization. A mental status examination revealed that the veteran was quite upset by auditory hallucinations. He was rather vague and disconnected, and affect was blunted. He was in rather poor contact with reality. The diagnosis was schizophrenia, chronic, undifferentiated type. The examiner opined that the veteran had been sick for a much longer period of time than he admitted. Based on that examination, the veteran was granted entitlement to service connection for schizophrenia, chronic, undifferentiated type, and was assigned a 50 percent rating. Since that time, the veteran has continued to receive treatment for his psychiatric disorder and has been hospitalized on several occasions. After each period of hospitalization, he was granted a temporary total rating. The veteran was hospitalized from March 1973 to May 1973 primarily for auditory hallucinations which were somewhat controlled on medication. In a June 1973 rating decision, the 50 percent rating was confirmed and continued. In August 1974, he was afforded a VA psychiatric examination. The veteran's primary manifestation of his psychiatric disorder at that time was auditory hallucinations. He reported that he had been unemployed for 6 months. It was noted that he was thin, poorly dressed, unwashed, unshaven, and inappropriately dressed. The diagnosis was chronic schizophrenic reaction, paranoid type. In a December 1974 rating decision, an increased rating of 70 percent was granted and the veteran was found to be individually unemployable. In a February 1976 rating decision, his total rating for unemployability was reduced to the 70 percent schedular evaluation since the veteran failed to return an employment questionnaire. In August 1977, the veteran was afforded a VA psychiatric examination. At the time of the examination, he appeared untidy and had a facial tic. He was alert, oriented in all spheres, cooperative, and conspicuously restless. He stammered and spoke in a tremulous voice. Mood was markedly apprehensive and mildly depressed, affect was flat, thought processes were concrete and were characterized by loose associations and tangentiality. Some of the veteran's descriptions of his subjective experiences were quite obscure and had an autistic quality. Thought content was characterized by autistic thinking and recurrent auditory hallucinations. Comprehension was good, judgment was fair, superficial insight was fair, and the veteran was well aware of his psychiatric illness. Reality testing appeared to be fairly well preserved. Intellectual functions were grossly intact and the veteran appeared to be of average intelligence. It was noted that the veteran was employed as a dishwasher. The diagnosis was schizophrenia, paranoid type, in partial remission, now manifested by thought disorder, flat affect, marked anxiety, mild depression, autism, facial tics, and defensive withholding of information and minimizing of problems. Degree of industrial impairment was severe and degree of social impairment was moderately severe. In a subsequent September 1977 rating decision, the 70 percent rating was confirmed and continued. The veteran was hospitalized from December 1978 to April 1979. It was noted that the veteran was not exhibiting any manifestations of schizophrenia. Based on that report, the RO found that the veteran's psychiatric disorder had improved and reduced his rating to 50 percent in a June 1979 rating decision. In October 1982, the veteran was afforded a VA examination which revealed that the veteran was exhibiting manifestations of a psychiatric disorder. Specifically, the veteran appeared disheveled, alert, cooperative, and oriented in all spheres. His mood was extremely anxious and his affect was inappropriate at times. He seemed to be preoccupied, responded very little to questions, and was guarded and suspicious. Thought processes were concrete and no looseness of association was noted. His sensorium was clear, memory seemed intact, comprehension and judgment were adequate, reality testing was preserved, and no suicidal or homicidal ideations were noted. It was noted that the veteran was unemployed. The diagnosis was schizophrenia, chronic, paranoid type, characterized by free floating anxiety, inappropriate affect, evidence of though blocking, extreme guardedness and suspiciousness, social withdrawal and insomnia. The degree of social and industrial impairment was severe. In a November 1982 rating decision, the 50 percent rating was confirmed and continued. The veteran was hospitalized from October 1982 to November 1982 for manifestations of his schizophrenia, especially auditory hallucinations. In April 1983, he was afforded a VA psychiatric examination. At the time of the examination, he appeared alert and oriented in all spheres. His mood was anxious and affect was flat. He reported auditory hallucinations, but there was no evidence of delusions. The veteran's thought processes were concrete. His thought contents centered around the auditory hallucinations and his inability to concentrate. His sensorium was clear, memory was intact, comprehension and judgment were adequate, superficial insight was fair, and no suicidal or homicidal ideation were present. The diagnosis was schizophrenia, chronic, paranoid type, characterized by diffuse anxiety, flat affect, occasional auditory hallucinations, inability to concentrate, concrete thought processes, insomnia, and social withdrawal. The degree of social and industrial impairment was severe. The veteran's 50 percent rating was confirmed and continued in a May 1983 rating decision. In April 1985, the veteran was afforded a VA psychiatric examination. At the time of the examination, the veteran appeared alert, cooperative, and oriented in all spheres. His mood was anxious and his affect was flat. He reported auditory hallucinations. The veteran's thought processes were concrete. His thought contents centered around the auditory hallucinations and his inability to be around others. His sensorium was clear, memory was intact, comprehension and judgment were adequate, superficial insight was fair, and no suicidal or homicidal ideation were present. It was noted that the veteran was attending the Vocational Rehabilitation Trade School and was taking a course in welding. The diagnosis was schizophrenia, chronic, paranoid type, in partial remission, characterized by diffuse anxiety, flat affect, auditory hallucinations, concrete thought processes, some suspiciousness and guardedness, insomnia, and social withdrawal. The degree of social and industrial impairment was moderate to severe. The veteran's 50 percent rating was confirmed and continued in an October 1985 rating decision. The veteran was hospitalized for manifestations of his schizophrenia from May 1987 to September 1987. Mental status examination revealed that the veteran was alert, cooperative, relevant, and coherent. He was having auditory hallucinations, but was evasive about the content and some blocking was noted. His sensorium was clear, he was oriented, memory was intact, affect was blunted, mood was somewhat depressed, insight and judgment was poor, and no suicidal ideation was noted. In an October 1987 rating decision, the veteran's 50 percent rating was confirmed and continued. In September 1988, the veteran was afforded a VA psychiatric examination. Mental status examination revealed that he was cooperative and answered questions in a coherent and relevant fashion. However, he had problems with stuttering. He was oriented in all spheres and sensorium was clear. He denied suicidal and homicidal ideation, but admitted paranoia. He reported auditory, but no visual hallucinations. It was noted that the veteran was last employed in 1981 as a dishwasher. The diagnosis was schizophrenia, paranoid type with a severe degree of emotional impairment. In a November 1988 rating decision, the 50 percent rating was confirmed and continued. In November 1989, the veteran was afforded a VA psychiatric examination. Mental status examination revealed that the veteran had problems with stuttering. He was oriented in all spheres and sensorium was clear. He denied present suicidal and homicidal ideation, but admitted having such in the past. He reported auditory hallucinations and paranoia. His memory was intact. It was noted that the veteran had been previously employed as a welder, dishwasher, and street cleaner and that he was last employed in 1982. The diagnosis was schizophrenia, paranoid type with a moderate degree of emotional impairment. In a November 1988 rating decision, the 50 percent rating was confirmed and continued. In December 1990, the veteran was afforded a VA psychiatric examination. Mental status examination revealed that the veteran answered all questions in a coherent and relevant manner. He was oriented in all spheres and sensorium was clear. He denied suicidal and homicidal ideation. He reported auditory and visual hallucinations and paranoia. His memory was intact. There was no evidence of a psychotic thought process. It was noted that the veteran was employed doing demolition work on a part-time basis. The diagnosis was schizophrenia, paranoid type with a moderate degree of emotional impairment. In a January 1991 rating decision, the RO proposed to reduce the evaluation for schizophrenia from 50 percent to 30 percent. The RO noted that the November 1989 VA examination suggested improvement in the veteran's service-connected disorder. The prior 50 percent rating was noted to be continued in the January 1990 rating decision pending re-examination in one year. The RO noted that the subsequent December 1990 VA examination also showed improvement, thus, confirming the findings of the 1989 examination. Therefore, the reduction to 30 percent was proposed. The veteran appealed that determination. The Board notes that 38 C.F.R. § 3.344 (1994) governs examination reports indicating improvement. That regulation states that rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and regulations governing disability compensation and pension. It is essential that the entire record of examinations and the medical- industrial history be reviewed to ascertain whether the recent examination is full and complete. Ratings on account of diseases subject to temporary or episodic improvement, will not be reduced on any one examination. Moreover, though material improvement in the physical or mental condition is clearly reflected, the rating agency will considered whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. In support of his claim, the veteran testified at a personal hearing at the RO in March 1991. At that time, the representative pointed out that the veteran has been assigned a rating of 50 percent or 70 percent since he was initially granted service connection for schizophrenia. The representative asserted that the veteran's industrial impairment was not considered by the RO and contended that the veteran was severely industrially impaired. The veteran related that he still experienced auditory hallucinations and paranoia. He reported that he had been unable to maintain employment due to his inability to concentrate or just because he began "feeling bad." He further related that he was taking medication to control his psychiatric disorder. He further reported that he was on a waiting list for a custodial job at the postal service and believed that he would be able to handle that employment. In March 1991, the hearing officer indicated that the reduction to 30 percent for service-connected schizophrenia was confirmed and continued. In an April 1991 rating decision, the reduction was confirmed and continued. In an April 1992 decision, the Board remanded this case for a VA psychiatric examination and for VA treatment records. Treatment records dated from April 1992 to February 1993 revealed treatment for the veteran's psychiatric disorder, primarily for auditory hallucinations. The veteran indicated during treatment that he was not interested in increasing his medication and was seeking employment. Although he reported auditory hallucinations, he denied depression and related that he was sleeping well and had a good appetite. In connection with his current claim, the veteran was afforded a VA examination in January 1993. The Board notes that the examiner did not have access to the claims file at the time of the examination. Mental status examination revealed that the veteran had a problem with stuttering. He was oriented in all spheres and sensorium was clear. He answered all questions in a coherent and relevant fashion. He reported auditory, but not visual hallucinations, although he reported experiencing visual hallucinations in the past. He denied any substance or alcohol abuse. His general fund of information was fair, judgment was fair, and intelligence was average. His recent and remote memory was fairly much intact. The veteran did not exhibit paranoia during the interview, but admitted to being paranoid. He was marginally integrated. It was noted that the veteran had a sporadic work history and had had difficulty working with others in the past. The diagnosis was schizophrenia, paranoid type. The examiner noted that the veteran has shown over the years marked social isolation and has a long history of auditory and visual hallucinations and paranoia. He noted that the veteran showed a lack of initiative and had paranoid ideations. No delusions were noted. The veteran showed definite social and industrial impairment, but not to a considerable extent. The degree of emotional impairment was noted to be moderate. Since the last VA examiner did not have access to the claims file, the veteran was afforded another VA psychiatric examination in June 1994. Mental status examination revealed that the veteran was in no acute distress, was cooperative and attentive, had good eye contact and rapport, appeared friendly and interacted well with the interviewer. The veteran's speech was normal in rate, tone, and volume. His affect was somewhat blunted. The veteran's thought process was goal-oriented and there was no looseness of association or flight of ideas. The veteran denied suicidal or homicidal ideation. He reported auditory, but not visual hallucinations. There were no ideas of reference, no delusions, and no paranoia. Cognitively, he was alert and oriented to all spheres. He was able to remember three out of three objects in five minutes. He performed serial threes times four. His judgment and insight were fair. The diagnosis was chronic paranoid schizophrenia, in remission. The veteran and his representative currently assert that the prior 50 percent rating should be restored for his service- connected psychiatric disorder. The evaluation assigned for a service-connected disability is established by comparing the manifestations indicated in the recent medical findings with the criteria in the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (1994). When there is a question as to which of two evaluations should 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 (1994). Under the VA's Schedule for Rating Disabilities, schizophrenia, paranoid type, is rated under Diagnostic Code 9203. The rating schedule provides a a 100 percent rating for active psychotic manifestations of such extent, severity, depth, persistence or bizarreness as to produce total social and industrial inadaptability. The rating schedule provides a 70 percent rating for psychotic disorders with lesser symptomatology such as to produce severe impairment of social and industrial adaptability; a 50 percent rating for psychotic disorders with considerable impairment of social and industrial adaptability; and a 30 percent rating for psychotic disorders with definite impairment of social and industrial adaptability. 38 C.F.R. Diagnostic Code 9203 (1994). The veteran's representative pointed out that the veteran's degree of industrial impairment was not properly considered by the RO. The Board observes that, as noted by the VA psychiatric examiners, the veteran has a long and extensive history of social withdrawal and sporadic employment. Although the veteran has been employed in some manner in the past, the record reveals that he had difficulty retaining such employment due to his psychiatric disorder. The Board notes that the veteran has recently shown some improvement in his disorder as noted on the past several VA examinations. In fact, his most recent VA examination indicated that his schizophrenia is currently in remission. However, the Board observes that the veteran is taking psychiatric medication to control his disorder and he still reports auditory hallucinations and feelings of paranoia. In view of the veteran's long history of considerable social and industrial impairment due to his service-connected schizophrenia, the Board finds that the recent medical evidence does not make it reasonably certain that the recent improvement in his psychiatric disorder will be maintained by the veteran under the ordinary conditions of his lifestyle. Therefore, in light of the veteran's long history of social withdrawal and industrial impairment, the Board finds that his prior 50 percent rating should be restored. However, the Board finds that the veteran's current manifestations of schizophrenia, paranoid type, are not consistent with a rating higher than 50 percent under Diagnostic Code 9203 since his psychiatric disorder has not undergone an increase in severity, was recently deemed to be in remission by a VA psychiatric examiner, and since the veteran does not exhibit severe impairment of social and industrial adaptability. Accordingly, the Board concludes that a restoration of the veteran's prior 50 percent rating for schizophrenia, paranoid type, is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 3.344 , Diagnostic Code 9203 (1994). ORDER The appeal is granted. EUGENE A. O'NEILL Member, Board of Veterans' Appeals (CONTINUED ON NEXT PAGE) 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.