BVA9508199 DOCKET NO. 93-12 936 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to an increased rating for chronic schizophrenia, undifferentiated type, with post traumatic stress disorder, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse. ATTORNEY FOR THE BOARD A. D. Jackson, Associate Counsel INTRODUCTION The veteran had active duty from November 1942 to January 1946. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in January 1993 from the Milwaukee, Wisconsin, Regional Office (RO) which expanded service connection for his psychiatric disorder to include post-traumatic stress disorder. However, this rating decision denied an increased rating for his psychiatric disorder, chronic schizophrenia, undifferentiated type with post-traumatic stress disorder. A personal hearing was held at the RO before a hearing officer in March 1993. CONTENTIONS OF APPELLANT ON APPEAL The veteran asserts that he should be granted a higher rating than 50 percent for his service-connected psychiatric disorder as this disorder is more severely disabling than the current evaluation reflects. Specifically, it is maintained that the disorder disables him to a degree that he is socially withdrawn, depressed, suicidal, irritable, and is easily angered. He also maintains that he suffers from flashbacks, nightmares, dissociative episodes, low self-esteem, crying spells and intrusive thoughts of combat. 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 preponderance of the evidence is against the claim for an increased rating for chronic schizophrenia, undifferentiated type, with post traumatic stress disorder. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the agency of original jurisdiction. 2. The veteran's clinical signs and manifestations of chronic schizophrenia, undifferentiated type, with post traumatic stress disorder, are not productive of severe social and industrial impairment. CONCLUSION OF LAW The schedular criteria for a rating in excess of 50 percent for chronic schizophrenia, undifferentiated type, with post traumatic stress disorder, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Codes 9204, 9411 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, it is necessary to determine whether the appellant has submitted a well-grounded claim and, if so, whether the Department of Veterans Affairs (VA) has assisted the appellant in properly developing his claim. A "well-grounded" claim is one that is plausible. The appellant's claim appears to be reasonably based. A review of the evidence further indicates that all relevant facts have been properly developed and that there is sufficient evidence upon which to fairly resolve the issue raised by the instant case. I. Disability History A rating decision dated in October 1958 granted service connection for anxiety reaction in a passive dependent personality, with a 30 percent disability rating assigned effective from March 2, 1954. That determination was based on the evidence then of record, including negative service medical records, an affiant's statement dated March 2, 1954, and subsequently dated clinical evaluation and treatment reports. In May 1960, the veteran underwent a VA neuropsychiatric examination. The examiner commented that the veteran was initially hyperactive and very tense. He was described as depressed over his emotional difficulties. Mental status examination was unremarkable, except that his abstract thinking was described as "only fair and rather concrete," and that his judgment was impaired only when under stress. The diagnosis was anxiety reaction, chronic. A rating decision dated in July 1960 reduced the veteran's disability rating to 10 percent. A VA psychiatrist submitted a letter dated in September 1960 that related the veteran's then current symptoms. The examiner commented that the veteran was considerably impaired. The diagnosis was schizophrenic reaction, undifferentiated type with "pseudoneurotic" symptoms of a psychosomatic nature, depressive trends, ideas of reference, auditory illusions and hallucinations and a definite persecutory trend. A rating decision dated in October 1960 restored the veteran's disability rating to 30 percent, effective from March 2, 1954, and reclassified the disability as chronic anxiety reaction. VA records indicate that the veteran was hospitalized in September 1961 with complaints that included backaches, nervousness, poor sleep, and shakiness. The examiner commented that psychological testing revealed an anxiety reaction in an individual who may have undergone a psychotic reaction in the past, but has been maintained in a neurotic adjustment for several years. The veteran's impairment was described as moderate. The diagnosis was anxiety reaction. On August 17, 1964, the veteran was recommended for psychiatric admission to a VA hospital following clinical consultation. He was admitted approximately one week later with complaints of nervousness and depression. He admitted to auditory hallucinations and reported thoughts of suicide, but denied any suicidal attempts. The final diagnosis was schizophrenic reaction, chronic, undifferentiated type. A rating decision dated in September 1964 increased the veteran's psychiatric disability evaluation to 100 percent, effective from August 17, 1964. The disability was reclassified as chronic schizo- affective reaction. The veteran underwent a September 1966 VA special psychiatric examination. The examiner reported that the veteran's schizophrenia was in partial remission with medication. He also noted that this was a sensitive stage and the possibility of regression still existed. The diagnosis was schizophrenic reaction, schizo-affective type in partial remission with medication. A rating decision dated in November 1966 reduced the veteran's disability rating to 70 percent. An August 1967 VA special psychiatric examination report shows that the veteran was oriented, cooperative and coherent. There were signs of restlessness and agitation. His affect was flat and there was evidence of psychomotor retardation. His memory and judgment were adequate. The diagnosis was schizophrenic reaction, schizo-affective type, in partial remission. A rating decision dated in September 1967 reduced the veteran's disability rating to 50 percent. A January 1969 special psychiatric examination report revealed that the veteran answered questions in a relevant and coherent manner. He complained of nightmares and tenseness with vomiting in the mornings. He denied auditory or visual hallucinations. The diagnosis was schizophrenia, undifferentiated type, by history, in remission, with residuals of anxiety neurosis. A rating decision in February 1969 reclassified the service- connected psychiatric disability as schizophrenic reaction, schizo-affective type, with anxiety neurosis. A report of a VA October 1990 psychiatric examination relates that the veteran was alert and oriented. He reported symptoms inclusive of nightmares, daily intrusive thoughts of combat, flashbacks, startle response and hypersensitivity to combat related stimuli. His affect was appropriate to content and his mood was euthymic. His attention, concentration and memory were mildly impaired. He denied any homicidal or suicidal ideations. The Axis I diagnoses were post-traumatic stress disorder and schizophrenic reaction with anxiety neurosis. With the exception of a temporary total hospitalization rating, the 50 percent evaluation has been continued to date, and was confirmed in a Board decision dated in September 1991. As noted above, the January 1993 raating decision expanded and reclassified the service-connected psychiatric disability as undifferentiated-type schizophrenia with post-traumatic stress disorder. II. Increased Rating The Board notes that ratings assigned for psychiatric disorders represent the impairment of social and industrial adaptability based on all of the evidence of record. 38 C.F.R. § 4.3 (1994). The veteran has been diagnosed with chronic schizophrenia, undifferentiated type and post-traumatic stress disorder. 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 (1994). A 50 percent evaluation is warranted for post- traumatic stress disorder where the ability to establish or maintain effective or favorable relationships with people is considerably impaired and where the reliability, flexibility, and efficiency levels are so reduced by reason of psychoneurotic symptoms as to result in considerable industrial impairment. A 70 percent evaluation is warranted for post-traumatic stress disorder where the ability to establish or maintain effective or favorable relationships with people is severely impaired and where the reliability, flexibility, and efficiency levels are so reduced by reason of psychoneurotic symptoms as to result in severe industrial impairment. 38 C.F.R. Part 4, Diagnostic Code 9411 (1994). A 50 percent rating is warranted for chronic undifferentiated-type schizophrenia with considerable impairment of social and industrial adaptability. Whereas, a 70 percent evaluation requires symptomatology which is less than 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 inadaptibilty. 38 C.F.R. Part 4, Diagnostic Code 9204 (1994). VA outpatient records developed between October 1991 and October 1992 relate that the veteran continued receiving psychiatric care. He continued to complain of flashbacks, depression, dissociative episodes, low self esteem, and combat related guilt. It was also indicated that the veteran had discontinued use of Prolixin and his Thorazine dosage was reduced in April 1991. VA clinical notations dated in February 1992 relate that the veteran had responded well to the reinstitution of Prolixin to his medication schedule. His mood reportedly improved. There was noted less anxiety and better temper control. The veteran received counseling in such areas as depression, smoking, anxiety control, self confidence, weight control, anger control and coping skills. He and his wife attended various support groups including post-traumatic stress disorder group therapy. The veteran underwent a VA psychiatric evaluation in November 1992. He reported that he was undergoing group therapy including post-traumatic stress disorder group therapy twice a week. He was being followed on an outpatient basis for medication management. He reported that he felt that he could no longer manage financially due to his wife's health costs and recent house improvements. He was oriented in all three spheres. His affect was extremely labile and his mood was depressed. There was no evidence of hallucinations, delusions or other psychotic symptomatology. The examiner commented that this lack of psychotic symptomatology was a result of his medication regimen. The veteran reported a history of multiple suicide gestures. There were no current suicidal or homicidal ideations. He reported combat related nightmares and flashbacks that were triggered by different environmental stimuli. His long term memory appeared intact with moderate impairment of short term recall. He was unable to do serial seven's but was successful with serial five's. He was unable to perform proverb interpretations and reported a diminished frustration tolerance. He described his past combat situations that were considered life threatening. He further related the avoidance of activities that reminded him of World War II. The veteran's reliability was considered fair. His judgment was considered fair to poor and his insight was limited. The Axis I diagnoses were chronic schizophrenia, undifferentiated type, unspecified, and post- traumatic stress disorder; Axis IV, severity of psychosocial stressors, moderate; and Axis V, global assessment functioning scale score, 55. The veteran and his wife presented testimony at a March 1993 personal hearing. He related his medical history and current symptoms. His symptoms included sleep impairment, outbursts of anger, crying spells, nightmares, memory impairment depression, driving difficulties, intrusive thoughts of combat, social isolation and suicidal ideations. He described his daily routine as consisting of going to church, taking naps, and having conversations with his wife. He reported that he was currently taking Prolixin and Thorazine. He reported severe monetary problems. His spouse indicated that the veteran experienced sleepless nights and undertook only minimal activities. The veteran related that he was employed at a factory for 17 years. His duties included testing water softeners. He retired as a result of longevity. In this regard, when evaluating psychiatric disabilities, it is necessary to consider, in addition to present symptomatology or its absence, the frequency, severity and duration of previous periods of discomfort. It is evident from the previous discussion, that the veteran's symptomatology produces significant social and industrial impairment. Nevertheless, it is noted that the veteran regularly attends church and veterans' associations meetings. There does not appear to be severe difficulties in his family relationships. He and his wife reported at his March 1993 personal hearing that he often saw his daughter and talked with other family members by telephone. Such a disability picture is not viewed as indicative of severe impairment in the ability to establish and maintain relationships. In addition to clinical findings and information that pertains to the veteran's social and industrial adjustment developed during the appeal period including his hearing testimony, the recently obtained GAF score is of significant probative value concerning the appropriateness of the assigned evaluation of 50 percent. Further, the examiner at the November 1992 VA examination commented that the veteran's reliability was fair. The veteran's medication regimen is apparently effective in at least controlling his more significant symptoms, and given other findings pertaining to his mental status and efforts to adapt, there is no reasonable basis for assigning an evaluation in excess of 50 percent at this time under either Diagnostic Code 9204 or 9411. Moreover, any psychiatric pathology that may interfere with industrial adaptability has been considered and is felt to be contemplated by the currently assigned 50 percent evaluation. The Board has carefully considered the testimony furnished by the veteran and his wife at his March 1993 personal hearing in which they reported his medical history and current symptomatology. Nevertheless, while the veteran's symptomatology shows some impairment in interpersonal and social functioning, this Board member finds that the psychiatric manifestations are not shown to be more than considerable in nature. Accordingly, because a higher evaluation requires severe impairment of social and industrial adaptability, 38 C.F.R. Part 4, Diagnostic Codes 9204, 9411 (1994), and in light of the veteran's psychiatric history and information developed pursuant to recent VA psychiatric examination, it is felt that a higher evaluation is not warranted. The Board has also considered the veteran's entitlement to an evaluation in excess of 50 percent pursuant to the provisions of 38 C.F.R. § 3.321 (1994); however, it is not found that this case presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. For instance, there is no indication that the veteran is required to undergo frequent hospitalizations. ORDER An increased evaluation for undifferentiated-type schizophrenia, with post-traumatic stress disorder, is denied. U. R. POWELL Member, Board of Veterans' Appeals 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.