Citation Nr: 0002966 Decision Date: 02/07/00 Archive Date: 02/10/00 DOCKET NO. 94-05 787 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an increased evaluation for service-connected schizophrenia, currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The veteran served on active duty from January 1980 to February 1981. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 1993 rating decision by the Huntington, West Virginia, Regional Office of the Department of Veterans Affairs (VA), which denied the veteran's claim for an increased evaluation in excess of 50 percent for his service-connected schizophrenia. In the course of the appeal, the veteran relocated to Virginia and his claims file was transferred to the jurisdiction of the Roanoke, Virginia, VA Regional Office (RO), in April 1998. FINDINGS OF FACT 1. The veteran's service-connected schizophrenia, chronic undifferentiated type, is manifested by recurrent, episodic exacerbation of his psychotic symptoms which necessitate repeated psychiatric hospitalizations several times per year. 2. Service-connected schizophrenia, chronic undifferentiated type, is of such severity and persistence as to produce complete social and industrial inadaptability. CONCLUSION OF LAW The criteria for a 100 percent evaluation for service- connected schizophrenia, chronic undifferentiated type, have been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.132, Diagnostic Code 9204 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran's service medical records show that he entered into active duty in January 1980 with a normal psychiatric examination and no prior medical history of a chronic psychiatric disorder. However, in November 1980 he was admitted for psychiatric treatment with an initial diagnosis of schizophreniform disorder. The records indicate that he began to display psychotic symptoms several months after entering service, culminating with his November 1980 hospitalization. He was given a definitive diagnosis of schizophrenia, undifferentiated type, and was deemed unfit for military service and given an honorable discharge on medical grounds in February 1981. In a December 1981 decision of the Huntington, West Virginia, VA Regional Office (Huntington), the veteran was granted service connection and a 30 percent evaluation for schizophrenia, undifferentiated type. At the time of the initial grant, he was deemed competent. Thereafter, the records and rating decisions associated with the claims file indicate that the veteran's psychiatric disability fluctuated in its degree of impairment over the years. In a November 1990 Huntington rating decision, his mental illness was assessed as 50 percent disabling, effective from October 1989. This 50 percent rating has remained in effect ever since then. The file indicates that the veteran had initiated and perfected an appeal of the aforementioned Huntington rating action of November 1990. However, after some substantial development of his appeal had been undertaken (which included providing him a VA compensation examination, obtaining his VA medical records, and scheduling a hearing for him at Huntington in May 1991), he abruptly withdrew his appeal in a signed and written request which was received by Huntington in November 1991. In response, Huntington sent him a letter in January 1992, which acknowledged his request. Huntington also advised him that no further action would be taken on his appeal unless additional evidence was received from him before March 29, 1992. However, after that date his appeal would be considered final. Thereafter, no further correspondence was received from him before the deadline and the appeal of the November 1990 rating decision was closed. In August 1992, the veteran sent a written inquiry to Huntington in which he requested information as to how he could obtain a rating increase. Huntington replied that same month with correspondence containing the requested instructions. Afterwards, in September 1992, the veteran provided information to support his request for an increased rating for service-connected schizophrenia. The medical records associated with his claim show that in August 1991, the veteran was hospitalized after he reported hearing voices because he had stopped taking his medication (Haldol). Upon reinstating regular use of his medication during the hospital course, the auditory hallucinations subsided and he became more comfortable and less fearful. His history at the time revealed that he lived by himself and was unemployed. On mental status examination he was described by the examiner as being neat in appearance and cooperative, attentive and polite. He did not have suicidal ideation. There was logical progression in the association of his ideas, though he had delusional trends of thought and experienced auditory hallucinations. He was found to be well-oriented as to time, place and person, and his memory for recent and past events was unimpaired. He was able to give a good account of himself and displayed insight into his condition and unimpaired judgment. His was discharged from the hospital in an improved condition and was considered to be competent. His diagnosis on release was schizoaffective disorder, with an Axis V assessment of poor adaptive functioning. A December 1991 VA medical report shows that the veteran had been placed in jail for an unspecified period. He was out of medication to control his schizophrenia. He was very tense and nervous and suffered from sleeplessness. The assessment was schizophrenia, no medication, with recent stressful events. The report shows that he was admitted for stabilization. Two days afterward, he was given an irregular discharge. A March 1992 VA medical report shows that the veteran was admitted for psychiatric hospitalization pursuant to his request that he receive help in reducing his auditory hallucinations. He reported on admission that he had discontinued use of his medication approximately 8 months earlier, thinking that he did not need it anymore. He related that for the 3 weeks prior to his admission he was hearing voices, including voices which instructed him to kill himself. He stated that he was able to control himself from acting on these voices, and he denied having any suicidal thoughts of his own. He admitted to occasional alcohol use and also a history of marijuana use. The hospital course was to reinstate his use of Haldol, which alleviated his psychotic symptoms. He was discharged with a supply of medication and was advised to take it regularly at the prescribed times and to maintain follow-up appointments with VA. His diagnosis was acute exacerbation of chronic undifferentiated schizophrenia and alcohol abuse, with a Global Assessment of Functioning (GAF) score of 50. He was deemed competent for VA purposes. For his work status, he was deemed permanently disabled. (Physical examination of the veteran was essentially within normal limits at the time of his hospitalization.) The report of a May 1993 VA compensation examination shows that the veteran's psychiatric complaints were that he experienced marked auditory hallucinations, though he also stated that these were less at the time of the examination. He reported that he was unable to drive a car because of his nerves, and that he experienced headaches and blackouts. He also related a history of alcohol abuse, but he also was reportedly reducing his alcohol intake. He admitted that he had experimented with drugs previously, but denied using them any more. The report shows that he had been jailed from November 1992 to January 1993 for disturbing the peace. On mental status examination, the veteran was neat and cooperative and spoke audibly but irrationally at times. He discussed his auditory and visual hallucinations and delusions, which involved his conversations with God and angels. The examiner noted that there was no evidence of any psychosis or thought disorder elicited. The veteran's thinking was characterized as being somewhat bizarre at times, and his abstract thinking revealed concretization. He demonstrated the ability to recall 7 digits forward and 5 digits backward. The examiner did not note any definite evidence of organicity. No active homicidal or suicidal ideations were obtained. The veteran's insight was regarded to be poor. His daily functioning and personality assessment shows that he had never married and lived by himself. He was under the care of a physician who had prescribed him several medications (including Navane). The veteran smoked cigarettes and occasionally used alcohol. His interests included traveling, reading, hunting and listening to music. He was able to take care of his personal chores and maintain his hygiene. The examiner's diagnosis was chronic schizophrenia, undifferentiated type, with a history of substance abuse. A VA inpatient treatment report shows that the veteran was psychiatrically hospitalized from April 26, 1993 to May 2, 1993, for complaints of auditory hallucinations which had reportedly instructed him to hurt himself. At the time of admission, the veteran admitted that he had not taken his psychiatric medication because he did not think that he needed it. Mental examination revealed him to be friendly and cooperative. He manifested auditory hallucinations but had no suicidal ideations or delusional trends of thought. He appeared to be well-oriented to time, place and person, gave a good account of himself, and displayed insight into his condition with unimpaired judgment. The planned treatment was to administer injections of Haldol Decanoate, at regular four-week intervals. The first injection appeared to lessen the auditory hallucinations, and it was planned to give him his next dose on May 26, 1993. He was also scheduled to attend the hospital's Behavioral Science Facility after staying one month. However, shortly after his admission, the veteran abruptly requested to be discharged from inpatient care after having expressed displeasure at having to accept instructions while hospitalized. He request was granted against his psychiatrist's medical advice, and he was released from the hospital on May 2, 1993. The diagnosis on discharge was schizophrenia, undifferentiated type, with an Axis V assessment of poor social functioning. His condition on discharge was regarded as improved. He was deemed to be not incompetent. The report of a July 1993 VA hospitalization shows that the veteran was admitted for inpatient psychiatric treatment for a period of six days following complaints of auditory hallucinations which affected his sleep and made him edgy, depressed and paranoid. He denied having any suicidal or homicidal ideations and did not report experiencing auditory hallucinations of the "command" type. He also denied using any alcohol or drugs, although the treating physician questioned the veteran's historical reliability in this regard. At the time of admission, he denied using any medications for his psychiatric illness, but reported having been given Haldol in an unknown dosage in the past. He was homeless, and on admission he presented himself as a disheveled, cooperative patient who wore dirty clothes. His speech was neither slurred nor pressured. His affect was slightly flat, blunted and inappropriate to his mood. He was oriented times three and alert, and he displayed concrete, linear, logical thinking with occasional tangentiality. On admission, he was diagnosed with chronic undifferentiated schizophrenia, with a GAF assessment of 40. The examiner noted that the veteran had increased auditory hallucinations. The hospital course was to administer the veteran Haldol and Cogentin, both medications given to him in two daily doses. During treatment he was quiet, calm and cooperative. With medication he reported a disappearance of his auditory hallucinations. After six days of inpatient treatment, he requested to leave the hospital in order to keep an appointment with his state social services office. He was not deemed to be a danger to himself or others at the time, and he was given a regular hospital discharge with a 30-day supply of Haldol and Cogentin (with no refills). He was instructed to take both medications twice daily. On discharge, he was deemed competent for VA purposes. His work status was classified as disabled. A December 1993 VA medical report shows that the veteran was admitted for two days of inpatient treatment after he entered a VA medical facility with complaints of feeling violent, though he denied any history of suicide attempt or violent behavior. The treating physician noted in the report that the veteran had a diagnosis of chronic undifferentiated schizophrenia, according to his old medical chart. The veteran was subsequently transferred after his second day to another VA hospital. The inpatient treatment report of the second VA hospital shows that he was admitted with a diagnosis of chronic undifferentiated schizophrenia and alcohol abuse, and he was hospitalized for ten days in December 1993 for exacerbation of psychosis due to non- compliance with medication. On admission, he reported having increased auditory hallucinations. He also reported that he had a personal fear of losing control of himself and hurting others, albeit without a history of having done so in the past, or possessing an intent or desire to do so on admission. The December 1993 VA hospital report shows that the veteran had a history of poor compliance with his medication regimen and with maintaining his follow-up appointments. He denied having used alcohol for a period of one month. His primary complaint was increased auditory hallucinations and of feeling depressed. His mental status on admission revealed a disheveled and very quiet man who was positive for auditory hallucinations. His speech was occasionally slurred and dysarthric secondary to possible dystonia. His emotions were blunted, and he displayed tangential thinking, paucity of speech, and marked blocking. He denied having any suicidal or homicidal ideation. The hospital course shows that the veteran quickly stabilized, and that his auditory hallucinations resolved with medication. The treating physician commented in the report that she believed the veteran would have benefited from a longer inpatient stay. However, the veteran requested a hospital discharge to be with his family for the holidays, and the physician did not deem him to be committable at that time. The examiner spoke with the veteran's sister, who concurred and arranged to wire him funds to pay for transport home. The veteran was discharged with a 30-day supply (and no refills) of Haldol to be taken twice daily; Haldol Decanoate to be taken every four weeks; and Cogentin to be taken twice daily. The veteran planned to make his own follow-up appointment. On separation, he was diagnosed with chronic undifferentiated schizophrenia and history of alcohol abuse, with an Axis V assessment of fair global functioning. He was deemed competent for VA purposes, though his work status was regarded as permanently disabled. An additional report shows that the discharge goals for his period of hospitalization in December 1993 were not accomplished. A series of VA hospital reports, dated in January 1994, show that the veteran was admitted for medication therapy (Haldol and Cogentin) and consultation. At the time of his admission, he was homeless. He reported a history of regular alcohol use over the last ten years. After a week of inpatient treatment, he was judged to be alert, oriented, and in no acute distress. He was released to the psychiatric clinic with a diagnosis of schizophrenia and was issued a 30- day supply of medication. A physician commented that it was doubtful that the veteran took his medications as instructed. A February 1994 VA medical report shows that the veteran reported that his auditory hallucinations had decreased with the use of medication. However, he still complained of feeling tense, anxious and depressed, and his physician noted that he displayed some tardive dyskinesia. He was diagnosed with chronic undifferentiated-type schizophrenia, in partial remission. The report of an August 1994 VA medical report shows that the veteran reported having auditory hallucinations and complained of headaches and of feeling a little nervous. A physician noted that the veteran had a history of schizophrenia and a head injury incurred at age 10 with traumatic seizures. The veteran had reportedly not taken his psychiatric medication for several months, having run out of medication and then failing to keep his treatment appointments. Mental status examination revealed that he was positive for auditory hallucinations. He was conscious, cooperative and oriented. His affect was slightly anxious and blunted, and he displayed normal eye contact and impulse control and appeared to be cognitively intact. His speech was normal, his thoughts were logical and goal-directed, and his perceptions were non-delusional. The examiner assessed him as being not acutely psychotic, nor suicidal or homicidal. The diagnosis was chronic schizophrenia, headaches, and organic brain syndrome. A VA medical report shows that the veteran was psychiatrically hospitalized for over one week in early November 1994 for complaints of hearing voices in his head. On admission, he reported that he had not taken his medication in the past six months. He admitted to occasional use of alcohol. The report noted that he lived alone in a trailer, and that he was brought into the VA hospital by his brother. Mental status examination revealed him to be a disheveled man in no acute distress who was cooperative with the examiner. He was cognitively alert and intact and oriented in three spheres. He displayed logical thought processes and linear, coherent thinking with no looseness of associations or flight of ideas. His affect was slightly restricted and his mood was depressed. His judgment and insight to his condition was poor. The November 1994 VA hospital course shows that the veteran was admitted for mild to moderate exacerbation of chronic schizophrenia secondary to his non-compliance with Haldol medication. He expressed dislike for Haldol and was prescribed Navane. The report shows that good results towards alleviating his symptoms were obtained with Navane. His auditory hallucinations disappeared and his cognitive functions returned to normal. He was discharged with a supply of medication and instructions for its use. He was judged at the time to be competent for VA purposes. In a written statement directed to VA and dated in November 1994, private staff psychiatrist Arturo R. Lumapas, M.D., of Huntington State Hospital stated that, in his opinion, the veteran was not competent to handle his own affairs due to schizophrenia, chronic undifferentiated type, and alcohol dependence. Dr. Lumapas advised VA that the veteran needed the assistance of a payee and recommended that the veteran's brother be assigned this role. In a January 1995 written statement to VA, the veteran concurred with Dr. Lumapas' conclusion and recommendation. He requested that his brother be designated to be his payee, or that he otherwise be given fiduciary responsibilities over the veteran's VA-related affairs. Pursuant to the conclusion of Dr. Lumapas, the Huntington RO issued a January 1995 decision which proposed to rate the veteran incompetent for purposes of payment of VA benefits. It is observed that a later rating action of March 1995 determined that no further action would be taken on the incompetency proposal because a medical report from the VAMC, Salem determined the veteran to be competent. A November 1994 VA treatment report shows that the veteran's sister had contacted VA and requested that they accept the transfer of the veteran from Welch Emergency Hospital (a private medical facility) to the inpatient care of a VA medical facility for treatment of schizophrenia. The report indicates that the veteran had apparently left the Welch Hospital emergency room on November 2, 1994, against medical advice, and that he had also been advised of the dangers of alcohol and substance abuse. A January 1995 VA psychiatric treatment report shows that the veteran was accepted for treatment for schizophrenia following discharge from Huntington State Hospital for two weeks of medication therapy. A physician noted that the veteran's family asked that the veteran's medication be administered via injection, due to his history of non- compliance with medication. A February 1995 VA medical report shows that the veteran had a diagnosis of active schizophrenia since military service. The report notes that treatment of the veteran's illness was complicated by his 17-year history of alcohol abuse and non- compliance with his medication. At the time of the treatment, the veteran was in a residency treatment program and was having good results. Relevant private treatment records, dated in August 1992 and received by VA in July 1995, show that in August 1992, the veteran was admitted to Southern Highlands Community Mental Health Center for exacerbation of schizophrenia. The veteran had reportedly displayed psychotic behavior which included running about and screaming in his apartment and talking to non-existent persons, which had reportedly frightened his neighbors. He also was detained by the police after having been discovered walking alone at night, talking to himself and disturbing his neighbors. On admission, he admitted to not taking his prescribed psychiatric medication. The veteran was treated until September 1992 and released. Additional records from to Southern Highlands Community Mental Health Center show that the veteran appeared for a treatment appointment in November 1992, during which time he exhibited anxious and impatient behavior. He acted irrationally and reported that "There are aberrations all around me! I'm leaving!" and abruptly ran out of the examiner's office in a wild manner. The assessment was that he was unstable, and that his family believed he was not taking his medication. Reports dated in December 1992 indicate that the veteran had been arrested and jailed. He was experiencing visual and auditory hallucinations, and his mother contacted the private facility and requested that they admit him for treatment as he was not in compliant with his medication. Reports dated in April 1993 show that the veteran appeared with complaints of auditory and visual hallucinations. Private medical reports from Huntington State Hospital show that the veteran received psychiatric hospitalization from November 1994 to December 1994 for acute exacerbation of chronic undifferentiated-type schizophrenia with alcohol abuse. On admission, he was experiencing auditory hallucinations and had reportedly not been in compliance with taking his medications. He was noted to have disordered, illogical and incoherent thoughts, with paranoid behavior. He did not display any insight into his condition. His condition improved thereafter, following inpatient treatment and re-instatement of medication. However, on December 1, 1994, he escaped from the hospital. He returned within a day and was re-admitted, re-administered his medications, and placed on risk-elopement precaution protocols for a period of two weeks. Thereafter, he was released from the hospital to a therapy program with a prescribed medication regimen. The December 1994 private hospital report shows that the veteran's anticipated problems following his discharge were that he would again become noncompliant with his medication and resume drinking alcohol or abusing other substances. A physician predicted that the veteran might need to be admitted to a VA hospital. His discharge diagnoses were schizophrenia, chronic undifferentiated type with acute exacerbation, and alcohol dependence. His psychosocial and environment problems were listed on his Axis IV diagnosis as noncompliance with his medications, drinking alcohol, and auditory hallucinations. His GAF score was assessed as 30 at the time of discharge, with an assessment of 30 for the past year. The remainder of the veteran's claims file contains VA medical reports which show that the veteran received inpatient psychiatric treatment on multiple occasions for schizophrenia and alcohol abuse. The reports show that he was psychiatrically hospitalized on nine separate occasions between the period of May 1995 to March 1998. Specifically, he was hospitalized in May 1995, June 1995, February to March 1996, June 1996, July 1996, October to November 1996, March 1997, December 1997, and March 1998. These records, in general, show that the veteran would often times fail to comply with his medication instructions and drink alcohol, after which he would experience acute exacerbation of his psychotic symptoms, including hallucinations. He was described in the reports as being very cooperative and normal in appearance and behavior after he was admitted for inpatient treatment and placed on a controlled medication regimen without access to alcohol. Several reports show that he would express a sincere desire to seek permanent, regular employment as a carpenter or a construction worker. However, the reports also note that he related a history of not working since approximately 1984. The reports also show that his periods of increased desire to obtain regular employment were apparently only temporary phases that he would occasionally undergo, and that each time he attempted to pursue this goal, including one time with the help of his family, all his attempts ended in failure. Included in the aforementioned VA psychiatric hospital reports is the summary of the veteran's March 1997 admission for complaints of auditory hallucinations and for ingestion of 32 Sominex pills (a non-prescription sleep aid). He reportedly ingested these pills as a suicide attempt, as he stated at the time that he wanted to die in order to escape from having to hear the voices associated with his auditory hallucinations. The VA medical reports show that the veteran's GAF scores for his periods of VA hospitalization from 1995 to 1998, ranged from as low as 50 in February 1996, to as high as 70 in June 1996. A March 1998 VA hospital report shows that the veteran's mental status on admission revealed him to be a fairly groomed man whose speech was clear and coherent. He displayed a "down" mood, with a euthymic and slightly depressed affect. His cognitive functions were grossly intact, and he was active, alert, and oriented times three. His thought process was logical, relevant and coherent, though occasionally circumstantial, but without delusional content. He did not have any suicidal or homicidal ideation, plan or intent. His perception did not reveal any hallucinations or illusions in any modality, his judgment was poor, and he was found to have no insight as to his problems. On discharge, he was diagnosed with chronic schizophrenia and alcohol dependence, with a GAF score of 65. II. Analysis To the extent that the veteran contends that his service- connected schizophrenia, chronic undifferentiated type, is productive of a greater level of impairment than that which is reflected by the 50 percent evaluation assigned, his claim for an increased rating is well-grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991), in that it is not inherently implausible. See Proscelle v. Derwinski, 2 Vet. App. 629, 631 (1992). Relevant evidence has been properly developed with regard to this issue, and no further assistance is required to comply with VA's duty to assist. Id. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Separate diagnostic codes identify the various disabilities. 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 (1999). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10 (1999). In the current appeal, the veteran's service-connected schizophrenia, chronic undifferentiated type, has been evaluated by the RO following consideration of the old and new schedular criteria for rating psychotic disorders contained in 38 C.F.R. § 4.132, Diagnostic Code 9204 (1996), and 38 C.F.R. § 4.130, Diagnostic Code 9204 (1999). In this regard, the regulations were changed effective November 7, 1996. Therefore, in the case at issue, the Board must also consider the applicability of the provisions of both the old and the new ratings schedule for evaluating undifferentiated- type schizophrenia and rate this psychiatric disability using the version of the regulations which are most favorable to his claim. See Karnas v. Derwinski, 1 Vet. App 308 (1991). However, because effective date rules under 38 U.S.C.A. § 5110 (West 1991 & Supp.1999) prohibit an award based on a liberalizing law or regulation for the period prior to the effective date of the law or regulation, the revised psychiatric rating criteria are not for application for the period prior to November 7, 1996. See DeSousa v. Gober, 10 Vet. App. 461 (1997). The veteran's service-connected schizophrenia is currently rated as 50 percent disabling, and this rating has been in effect since October 1989. In 1992, the veteran reopened his claim and sought a rating in excess of 50 percent. Prior to the revisions of November 7, 1996, the regulations for rating schizophrenia provided that a 50 percent evaluation is warranted for this disorder when there is considerable impairment of social and industrial adaptability. A 70 percent evaluation requires symptomatology which was less that that required for a 100 percent evaluation, but which nevertheless produces severe impairment of social and industrial adaptability. A 100 percent evaluation requires active psychotic manifestations of such extent, severity, depth, persistence, or bizarreness as to produce complete social and industrial inadaptability. 38 C.F.R. § 4.132, Diagnostic Code 9204 (pre-November 7, 1996). Applying the aforementioned pre-November 7, 1996 criteria to the facts of the case, the evidence tends to show that the veteran's schizophrenia produces complete social and industrial inadaptability. He separated from service due to schizophrenia in February 1981, and reportedly has not worked since 1984. The private and VA medical records associated with his file demonstrate that he has a history of repeated psychiatric hospitalization several times per year due to recurrent exacerbations of psychotic symptoms. These are primarily manifested by auditory hallucinations, and are a result of, among other things, his persistent noncompliance with his prescribed medications. On the positive side, the veteran's medical records also show that he is able to quickly obtain good results after reinstatement of the proper medication therapy and protocols, and his mental status examinations also present him to be an individual possessed of sufficient functional and mental capacity to be able to adhere to a medication regimen and to meet regularly scheduled clinical appointments. His lowest GAF score, as demonstrated by the evidence, is 50, indicating that he experiences some serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). (See Global Assessment of Functioning Scale contained in The American Psychiatric Association, Diagnostic & Statistical Manual, 4th Edition (1994)). However, these positive qualities reported above must be weighed against the clinical evidence showing the sheer frequency of the veteran's multiple psychiatric hospitalizations. Though he appears to have a rather high cognitive functional ability, he nevertheless possesses a clear and consistent history of repeated medicinal noncompliance, followed by exacerbations of schizophrenia and the need for inpatient admission and treatment several times per year, which would certainly interfere with his ability to work a regular and steady job. In addition to this already dismal psychiatric profile presented above, the veteran's employment history since 1984 is nonexistent, and he has met with repeated failure despite his apparently sincere and earnest attempts to obtain regular employment. The records indicate that he has experienced several periods of homelessness. In view of these facts, the Board concludes that the objective medical evidence presents a disability picture which more closely approximates that contemplated for a 100 percent rating under the old, pre-November 7, 1996 psychiatric rating schedule. See 38 C.F.R. § 4.7. This appellate decision has granted the veteran the maximum benefit provided by the laws and regulations, based on application of the older psychiatric rating schedule, which is the more favorable version of the regulations. It is thus in compliance with the decision of the U.S. Court of Appeals for Veterans Claims (Court) in Karnas v. Derwinski, 1 Vet. App 308 (1991). Further, the provisions of the older schedule are not subject to the effective date limitations prescribed by the Court's decision in DeSousa v. Gober, 10 Vet. App. 461 (1997). Thusly, there is no further need to consider the provisions of the revised rating regulations, as contained in 38 C.F.R. § 4.130, and to discuss their applicability to the issue on appeal. ORDER On application of the provisions of the rating schedule as it existed prior to November 7, 1996, an increased rating to 100 percent for service-connected schizophrenia, chronic undifferentiated type, is granted, subject to the applicable criteria pertaining to the payment of monetary benefits. Iris S. Sherman Member, Board of Veterans' Appeals