BVA9502818 DOCKET NO. 92-20 899 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to an increased rating for schizophrenia, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Robert E. P. Jones, Associate Counsel INTRODUCTION The veteran served on active duty from January 1972 to February 1974, from September 1974 to December 1977 and from March 1982 to December 1989. This matter came before the Board of Veterans' Appeals (Board) on appeal from a December 1991 rating decision by the Los Angeles, California, Regional Office (RO). The veteran's claim was remanded to the RO for further development in October 1993. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he is entitled to an increased rating for his service-connected schizophrenia. He asserts that he has been unable to work since May 1990 due to his service-connected schizophrenia and that he is experiencing severe financial stress. The veteran maintains that he has been found to be permanently and totally disabled by the Social Security Administration. 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 veteran's claim for an increased rating for schizophrenia and that a total rating based on individual unemployability is warranted. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran experiences considerable social and industrial impairment due to schizophrenia. His main symptoms are auditory hallucinations which increase when he is under stress, and a need for psychotropic medication. 3. As a result of schizophrenia, the veteran is unable to obtain and retain gainful employment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 50 percent for schizophrenia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.132, Code 9204 (1993). 2. Entitlement to a total rating based on individual unemployability is warranted. 38 C.F.R. § 4.16(b)(1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, the Board finds that the veteran has presented a claim which is plausible. 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. The veteran seeks a disability evaluation in excess of 50 percent for his service-connected psychiatric disorder. Service medical records reveal that the veteran received treatment for a psychiatric disorder. In September 1989 the veteran was recommended for discharge from service due to schizophreniform disorder. The veteran was discharged in December 1989. By rating action in February 1990, service connection was granted for a psychiatric disorder, classified as schizophreniform disorder, for which a 50 percent evaluation was assigned. VA outpatient treatment records dated from January 1990 to May 1993 show sporadic outpatient treatment for the veteran's psychiatric disorder. The veteran received inpatient treatment at a Department of Veterans Affairs (VA) medical center from May through July 1990. The veteran was admitted with complaints of hearing voices and "EPS" side effects. The veteran had a history of schizophreniform disorder and a history of hearing voices and paranoid ideations. On examination he reported hearing several voices telling him several things. He appeared rather suspicious and flat and with constricted affect or responses. He denied feelings of severe depression and past history of periods of depression or mania. On discharge he was alert and oriented to place, person and time. His affect was appropriate. His mood was fair. Though the veteran had some kind of paranoia, he was not acutely hallucinating or acutely psychotic. He was on the medications Loxipin, Cogentin, and Sinequan. In October 1990 the veteran was examined by a private psychiatrist, Reinaldo Faget, M.D. The veteran reported that he began to hear voices he believed to be Satan, telling him to kill his parents in June 1989. He reported that he was sent to Walter Reed Hospital for six months where he was diagnosed as having schizophrenia. The veteran reported that his medications were Benztropine, Thioridazine, and Doxepin. On mental status examination the veteran presented as mixed-up, restless, and perplexed. His speech was of average productivity delivered in a rather explosive manner and sometimes severely impaired by blocking. The veteran's thought content was affected by auditory hallucinations which he perceived as being Satan who instructed him to kill his parents. His capacity for abstract thinking was poor. The diagnosis was schizophrenia. Dr. Faget completed a medical assessment of ability to do work-related activities form. He reported that the veteran's work-related activities were not significantly limited by either ability to understand and remember or ability to sustain concentration and persistence. However, Dr. Faget noted that the veteran's work-related activities were limited by his limited abilities of social interaction and limited abilities of adaptation. The veteran received a Temporary Disability Retired List psychiatric examination in June 1991. The veteran reported many stressful events since retirement from the military. These included a nervous breakdown, divorce, and bankruptcy. The veteran reported an increase in his symptoms, primarily an increase in the auditory hallucinations. That was mainly a male voice that was self-deprecating and quite angry. He said the voices said things like "I hate my wife" and "kill my mother." The veteran denied any intent to actually kill his mother or anyone else but the voices were bothersome. The veteran stated that he had been quite depressed and he was grief-stricken over the loss of the relationship with his wife and his daughter. The veteran reported poor concentration. He was sleeping poorly and had low self-esteem. On examination the veteran showed some dramatic hand movements and vocal and facial expressions. His speech was rapid and his tone was loud and emphatic. His affect was sad and depressed and he was easily tearful. His mood was depressed. His thought processes were linear and goal-directed. The veteran showed no looseness of association or tangentiality. He had no flight of ideas. There was no paucity of thought and his thinking was spontaneous. His thought content included auditory hallucinations of a self-deprecating and angry nature. They included command hallucinations of which the veteran denied any wish or intent to follow. The veteran had some past suicidal ideations but claimed that he had not had any currently and did not have any plan or intent. The veteran had a strong sense of worthlessness. However, he did not describe hopelessness, helplessness, obsessions or compulsions. His judgment was intact and he was able to abstract well on proverbs, similarities, and general information. His cognition was intact completely. The veteran's medications were Mellaril and Doxepin. The assessment was schizophrenia, undifferentiated type, chronic, moderate, manifested by auditory hallucinations, history of cognitive slowing, and severe social and occupational dysfunction. His global assessment of functioning was estimated to be 60 and the best functioning in the past year was estimated to be 70. The veteran was afforded a VA psychiatric examination in December 1991. The veteran complained of difficulty sleeping, weight gain, and having no motivation to do anything. The veteran also reported auditory hallucinations that occurred when particularly stressed. The veteran responded affirmatively to virtually all questions with regards to symptomatology. This included feeling extremely depressed, anxious, hyperactive with racing thoughts with impulsivity, mood swings, and occasional suicidal ideations. It seemed that the veteran had a tendency to exaggerate symptoms. He reportedly had last worked in May 1990 as a box boy. He said he had a Master's degree in human resource management. On mental status examination the veteran's mood was slightly anxious but generally euthymic. Affect showed a normal range, stability, and appropriateness. Thought processes showed no evidence of any thought disorder and showed logical goal-directed speech. Thought content was negative for any suicidal ideations, homicidal ideations, auditory hallucinations, visual hallucinations, olfactory hallucinations, thought insertion, thought withdrawal, thought broadcasting or paranoid ideations during the interview. The veteran was fully alert and oriented times three. He was able to perform tasks of concentration and attention without difficulty when specifically tested. The examiner thought that the veteran tended to exaggerate his symptomatology or at least he seemed to do so during the interview process. The veteran may, in fact, have episodes of anxiety, depression, and possibly even transient auditory hallucinations when under stress. However, during the interview the examiner saw no demonstrable evidence that would support a full-blown Axis I psychiatric disorder. It seemed that the veteran's underlying personality structure and traits would dominate his psychopathology and presentation. The veteran appeared to have a rather low stress tolerance and was likely occupationally impaired to a moderate degree. In addition, his social impairment seemed moderately impaired as well. The Axis II diagnoses was histrionic and narcissistic personality traits. Global Assessment of Function Scale was currently 60 and in the past year, 70. The veteran received a VA examination by a psychologist in February 1994. The veteran reported that he had no history of auditory hallucinations prior to June 1989. He stated that he heard voices fairly consistently since that time. "It's like a male monster on the back of my shoulders that tells me what to say and do." He denied any history of visual or other hallucinations. The veteran reported that he attended the Knoxville VA Outpatient Clinic where he was maintained on Thioridazine, as well as Doxepin. He stated that the antipsychotic medication had helped diminish the frequency and the intensity of his voices, yet they persisted even up to the present time. The veteran's speech was loud and somewhat pressured, but otherwise spontaneous, goal-directed, and appropriate in content. Conversation revealed no evidence of psychosis at that time except for the veteran's own direct acknowledgment of ongoing hallucinations. There may had been a mild eccentricity in his speech content, indicating residuals of a schizophrenic disorder. The veteran's cognitive functioning was felt to be grossly intact in all areas. A shortened attention span was noticed. He appeared to possess intellectual abilities within the average range. His affect was genuinely appropriate but a few points he was overly cheerful and friendly for the situation. The veteran impressed the examiner as a socially anxious yet genuinely pleasant, enthusiastic and trusting individual who might be characteristically naive and passive in relating to others. The veteran completed the Millan Clinical Multiaxial Inventory (MCMI) without difficulty. The results were consistent with the notion that a psychotic level disorder had been present in the veteran's history but was fairly well controlled at that time. The test results were also positive for anxiety and depressive features of moderate intensity. The MCMI data were found to indicate the presence of a mixed personality disorder in the veteran. The veteran was likely to have a longstanding, well-ingrained pattern of disturbed interpersonal relations. Schizoid, avoidant and dependent features were the most prominent. The diagnostic impressions included schizophrenia of the unspecified type, chronic, moderate degree of impairment. Also noted was a depressive disorder of mild to moderate degree and a mixed personality disorder with schizoid, avoidant, dependent, and passive-aggressive features. The veteran was examined by a VA psychiatrist in February 1994. The veteran reported that he lived in an apartment in a hotel and took care of his daily activities, and handled his own finances. He stated that he had not worked in several years and had been reluctant to do so partly because he was concerned that he would not be able to maintain a position. The veteran was oriented to time, place and person as he had been for the most part since the examiner had been seeing him on a regular basis. The veteran continued to describe persecutory auditory delusions. In the past efforts to increase the veteran's antipsychotic medication had caused increased drowsiness. The examiner noted that the recent VA psychological testing was quite comprehensive and conclusions were endorsed by the VA psychiatrist. The examiner noted that the veteran remained competent for VA purposes. Social and industrial impairment secondary to Axis I remained considerable or severe. Inasmuch as the veteran had made no recent attempts at any type of employment it would be premature to say that he was unemployable or unable to maintain employment. The examiner noted that the VA psychologist had made an additional diagnosis of dysthymia but it was the examiner's opinion that it was primarily secondary to schizophrenia and not a separate entity. The diagnoses included chronic undifferentiated schizophrenia and mixed personality disorder not otherwise specified. The schedular criteria for evaluation greater than 50 percent for schizophrenia requires active psychotic manifestations of such an extent, severity, depth, persistence or bizarreness as to produce severe impairment of social and industrial adaptability. 38 C.F.R. § 4.132, Code 9204. The veteran continues to report persecutory auditory hallucinations and to need fairly significant neuropsychiatric medication. In December 1994, he was oriented to time, place and person. His speech was loud and pressured, but spontaneous, goal- directed, and appropriate. His conversation gave no indication of schizophrenia. He was living in an apartment, taking care of his personal affairs and finances. The examiner in February 1994 concluded that the veteran's condition had not changed. Given these findings and the remainder of the evidence of record, the Board finds that the current schedular evaluation is appropriate. The evidence is not so evenly balanced as to raise doubt regarding any material isssue. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.132, Code 9204. In reaching its decision, the Board has considered the complete history of the disability in question as well as the current clinical manifestations and the effect the disability may have on the earning capacity of the veteran. 38 C.F.R. §§ 4.1, 4.2 (1993). The criteria for an evaluation greater than 50 percent have not been met or approximated. 38 C.F.R. § 4.7. The Board finds, however, that the record supports the assignment of a total rating based on individual unemployability. The veteran has not been gainfully employed since his discharge from service in 1989, in large part due to his service-connected psychiatric disorder. As noted above, he continues to experience persecutory auditory hallucinations and takes daily psychotropic medication, which causes drowsiness. Significantly, his daily dosage of Mellaril was increased from 150 to 200 mg. following the December 1994 VA examination. Resolving all doubt in the veteran's favor, a total rating based on individual unemployability is warranted. 38 C.F.R. § 4.16(b). ORDER Entitlement to an increased rating in excess of 50 percent for schizophrenia is denied. Entitlement to a total rating based on individual unemployability is granted, subject to the law and regulations governing the payment of monetary benefits. WAYNE M. BRAEUER 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.