Citation Nr: 0000518 Decision Date: 01/07/00 Archive Date: 01/11/00 DOCKET NO. 97-28 848A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to an increased rating for schizophrenia, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The veteran served on active duty from September 1957 until September 1961. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) from a rating decision of August 1997 of the Chicago, Illinois Regional Office (RO) which denied an increased evaluation for the service-connected schizophrenia. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the RO. 2. The service-connected schizophrenia is currently manifested by symptoms which include anxiety and depression, and reported complaints of sleeplessness, auditory and visual hallucinations, some paranoia, ideas of reference and problems with concentration productive of occupational and social impairment with no more than reduced reliability and productivity. CONCLUSION OF LAW The schedular criteria for an evaluation of 50 percent evaluation for schizophrenia have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9205 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION By rating action dated in April 1962, service connection for schizophrenia was established. The veteran has been in receipt of a 30 percent disability evaluation for such since May 1969. He most recently attempted to reopen his claim for a higher rating in this regard in January 1997. The appellant and his representative assert that the symptoms associated with the veteran's service-connected schizophrenia are more severely disabling than reflected by the currently assigned disability evaluation and warrant a higher rating. It is contended that he has to see a psychiatrist every month, is unable to sleep at night without medication, is nervous during the day and has a tendency to decompensate at any time. Initially, the Board finds that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). A well-grounded claim is one that is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Here, the veteran's claim is well grounded because he has a service-connected psychiatric disorder and has submitted evidence that he claims demonstrates exacerbation of the disorder. See Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992). The Board finds 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). 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; 38 C.F.R. Part 4. Where entitlement to compensation has already been established and an increase in a disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The pertinent provisions of the Rating Schedule provide that a 30 percent rating is warranted where the psychiatric disorder is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted where the disorder is manifested by 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is 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); and an inability to establish and maintain effective relationships. A 100 evaluation is assigned when the service-connected psychiatric disability results in 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; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9205 (effective November 7, 1996). It is the defined and consistently applied policy of the VA to administer the law under a broad interpretation, consistent, however, with the facts shown in each case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3; See also 38 C.F.R. § 3.102 (1999). 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). Relevant clinical data received during the appeal period show that a VA staff psychiatrist wrote in February 1997 that the veteran had chronic paranoid schizophrenia and continued to receive medications to keep his symptoms under control. It was reported that he had had several psychiatric hospitalizations, the last of which had been in August 1995. It was the physician's opinion that the veteran was disabled due to his psychiatric condition, and had the propensity to experience exacerbation of symptoms unless he was maintained on medication. The veteran was afforded a VA examination for compensation and pension purposes in March 1997. It was noted that since his last examination, he had not been hospitalized, but had continued in monthly individual outpatient therapy and had been prescribed doxepin at bedtime. The veteran indicated that he was employed, that his finances were good and that his primary activities were watching television. He said that he went to church on Sundays. He said that he had trouble sleeping at night and that if he did not get his rest, he started hearing voices. He also related that he felt nervous and that under stress, he heard God speaking. It was noted that he was bothered by depression and also had visions. The appellant admitted to irritability, difficulty concentrating and trouble making decisions. He indicated that he felt insecure because of the events in his life. Upon mental status examination, the appellant was observed to be casually dressed. He appeared to be tense but not overtly hostile, resentful or uncooperative. He was well oriented, and indicated that he did not consider himself overly suspicious. It was noted that he felt that he was psychic and had premonitions of the future. He reiterated that he heard messages from God to help people, but that he was aware that it was all in his mind. It was reported that the veteran did experience ideas of reference with watching television, but did not think he could read other peoples' minds or vice versa. He did not think his thoughts were controlled by powers outside of himself. He was determined to be competent. The appellant was hospitalized at a VA facility between August and September 1997 with a complaint of hearing voices for the past 10 days telling him to do different things. He stated that he had decreased sleep and was irritable and tense. He denied hopelessness or a sad mood, and suicidal or homicidal thoughts. His wife reported he had been naked with a hat on for the past few days. Upon mental status examination, the veteran had good hygiene, was cooperative and had good eye contact. There were no abnormal movements. Speech was of normal rate and rhythm. Thought process was circumstantial. There was no suicidal or homicidal ideation. The veteran reported auditory hallucinations. He was oriented times three but abstraction was poor. He had fair insight and poor judgment. The veteran was admitted to the psychiatric unit for stabilization and was placed on multiple medications. It was observed that he was tangential at times, and appeared euthymic, but was behaving appropriately on the unit with the staff. It was reported that no bizarre behavior was noted throughout the hospital stay. It was noted, however, that he was still hearing voices. The veteran attended all group meetings and was compliant with his treatment regimen without complications. He eventually stated that he was less confused and was no longer hearing voices. He did, however, report "premonitions in my dreams." It was recorded upon discharge that the appellant was not employable at that time. A diagnosis of schizophrenia, paranoid type, chronic with acute exacerbation was rendered. It was noted that he had a General Assessment of Functioning score of 40 on admission and 70 on discharge. The veteran's treating physician, a VA staff psychiatrist, reiterated in June 1998 that the appellant continued to be symptomatic and needed to be on medication to control his illness. It was added that his condition decompensated when he was off medication and that he was significantly disabled. The appellant was most recently evaluated for compensation and pension purposes in July 1998. It was reported that since his last hospital admission, he had continued in follow-up treatment of monthly individual therapy. He stated that he needed additional medication because he was waking up early in the night and could not go back to sleep. It was noted that he was employed. He indicated with respect to social contacts that his wife and children talked to him, and that he had one friend who came by occasionally. The veteran indicated that he had been hearing voices over the past 12 months and that his mind went "off the deep end" and "snaps." He said that he was never really free of those symptoms, and that they would "come and go." He said that he had missed about 10 days from work during the past 12 months because of emotional problems. The veteran reported that he experienced visual hallucinations. He admitted to being suspicious, and thought that people were talking to him behind his back. He did not think that people could read his mind or vice versa. He thought that his thoughts were controlled by God and felt that there was some kind of destiny that he was repeating, and said it was hard to explain. It was noted that he had experienced ideas of reference, but was not currently having that experience. He continued to think that he had premonitions, but did not experience thought extraction on insertion. There was no evidence of grandiosity or euphoria. The appellant indicated that he became depressed because of his illness. He denied suicidal or homicidal ideation or attempts. He said that he had a fear of closed spaces, had difficulty concentrating and was quite irritable. Upon mental status examination, the appellant was cooperative and no motor abnormalities were observed. His mood seemed depressed. Sensorium was clear and speech was spontaneous but somewhat monotonous in tone. The veteran was oriented and did not appear to be experiencing any auditory hallucinations or systematized delusional thinking. He was unable to perform abstract thinking. Concentration did not appear to be impaired and judgment seemed to be intact. The veteran subsequently underwent a VA social and industrial survey in July 1998 which indicated that he was adequately groomed and dressed. Affect was observed to be flattened and mood was a bit anxious. Insight and judgment appeared to be good. It was noted that he had had 12 prior psychiatric hospitalizations. The veteran's employment history after service was detailed. It was reported that he had worked for the Post Office since 1983 and continued to work there full time as a custodian. He related that he had been feeling somewhat stressed since his wife had lost her job and that there was significant financial stress with difficulty paying bills. He indicated that he was compliant with his medication. The appellant said that he was in touch with his siblings by phone, and had some close friends who were also members of his family. It was noted in summary that the veteran had managed to function in occupational and social areas despite his illness, and that limitations seemed to relate to working at a job that he viewed as unchallenging, and maintaining some distance in all relationships. It was felt that thought processes appeared to be rather rigid and that stress tolerance was somewhat below normal. VA inpatient and outpatient clinic notes dated between May 1997 and August 1998 reflect continuing treatment and follow- up for the service-connected psychiatric disorder. Analysis The record reflects that the veteran's service-connected schizophrenia is currently manifested by symptoms which include anxiety and depression, and reported complaints of sleeplessness, auditory and visual hallucinations, some suspiciousness, ideas of reference and problems with concentration. The evidence indicates that he has been able to maintain long-term and steady employment and has a relatively stable life on continued medication and therapy. A longitudinal review of the record discloses, however, that the veteran's clinical course has been marked by relatively frequent and abrupt periods of hospitalization over the years despite ongoing intervention While VA clinic records dated between 1997 and 1998 indicate that the veteran's mental status had remained essentially stable, and a GAF score of 70 was recorded following hospitalization in August 1997, it is shown that the appellant reports that he is never free of such symptoms which include auditory and visual hallucination and mental turmoil. He indicated upon VA examination in July 1998 that he had missed at least 10 days from work over the past year due to emotional distress. The Board thus finds under the circumstances that the symptoms associated with the service-connected schizophrenic disorder result in occupational and social impairment with reduced reliability and productivity on the whole. Therefore, with consideration of 38 C.F.R. § 4.7, the benefit of any doubt is resolved in favor of the veteran by finding that the service-connected psychiatric disorder is 50 percent disabling according to the schedular criteria. However, the veteran's GAF score, social life, and overall clinical assessment are not consistent with the 70 percent psychoneurotic rating criteria as delineated above. He has not been shown to have suicidal ideation, obsessional rituals which interfere with routine activities, neglect of personal appearance, spatial disorientation or inability to establish and maintain effective relationships. As such, the service-connected disorder at issue more nearly approximates the requirements for a 50 percent disability rating in this regard. The Board is required to address the issue of entitlement to an extraschedular rating under 38 C.F.R. § 3.321 only in cases where the issue is expressly raised by the claimant or the record before the Board contains evidence of "exceptional or unusual" circumstances indicating that the rating schedule may be inadequate to compensate for the average impairment of earning capacity due to the disability. See VA O.G.C. Prec. Op. 6-96 (August 16, 1996). In this case, consideration of an extraschedular rating has not been expressly raised. Further, the record before the Board does not contain evidence of "exceptional or unusual" circumstances that would preclude the use of the regular rating schedule. ORDER An increased rating for schizophrenia is granted subject to controlling regulations governing the payment of monetary benefits. U. R. POWELL Member, Board of Veterans' Appeals