BVA9505747 DOCKET NO. 93-09 462 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Restoration of a 50 percent rating for service-connected schizophrenia, paranoid type, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Christopher P. Kissel, Associate Counsel INTRODUCTION The appellant served on active duty from November 1964 to April 1967, and from December 1967 to February 1972. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a March 1990 rating decision of the Chicago, Illinois, Department of Veterans Affairs Regional Office (VARO). CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that his service-connected schizophrenia, paranoid type, is of sufficient severity as to warrant restoration of the previously assigned 50 percent disability rating. He argues that the medical evidence of record does not establish sustained improvement of this disability such as to justify the reduction. 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(s). 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 appellant is entitled to restoration of the 50 percent disability evaluation for his service-connected schizophrenia, paranoid type. FINDINGS OF FACT 1. The appellant's schizophrenia, paranoid type, is currently manifested by symptoms of reported auditory hallucinations and feelings of loneliness, requiring regular outpatient treatment and a continuous regimen of psychotropic medication to control psychotic regressions, resulting in considerable social and industrial impairment. 2. Reduction of the appellant's 50 percent disability rating in March 1990, was not based upon sufficient medical evidence demonstrating sustained improvement in his service-connected schizophrenia, paranoid type. CONCLUSION OF LAW The criteria for restoration of the 30 percent disability evaluation to 50 percent disabling, effective from January 1, 1990, for the appellant's service-connected schizophrenia, paranoid type, are met. 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 Initially, the Board finds that the appellant has submitted evidence which is sufficient to justify a belief that his claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet.App. 78 (1990). Furthermore, the undersigned believes that this case has been adequately developed for appellate review purposes by the VA, and that a disposition on the merits is now in order. I. Factual Background By rating action in February 1984, VARO increased the evaluation assigned to the appellant's service-connected schizophrenia, paranoid type, from 30 to 50 percent disabling according to the schedular criteria under diagnostic code 9203. The medical evidence which was considered by VARO at that time consisted of a hospital report from the Illinois State Psychiatric Institute (ISPI) showing a period of hospitalization in July-August 1983. The appellant was admitted for evaluation of his complaints of auditory hallucinations, delusions, and tangential thinking. His Axis I discharge diagnosis was paranoid schizophrenia, chronic with acute exacerbation, and history of alcohol abuse. His course of hospitalization was described as follows: Patient was initiated on pharmacotherapy course of Haldol 10 mg., b.i.d., and Cogentin 2 mg., p.r.n. This was after patient spent 8 hours in [full leather restraints] for loud and threatening behavior on 7/20/83. Dosage was increased to Haldol 15 mg., b.i.d., and patient started to show marked improvement. Patient became less agitated and paranoid. He began to communicate to a much greater degree with staff and other patients. Titration down to Haldol 10 mg., b.i.d. was attempted on 8/08/83, but patient in following week started to become more agitated, threatening to injure another male patient, and was [complaining] of "racing thoughts" and "everything becoming pressurized." Patient was reinstituted on Haldol 15 mg., b.i.d. on 8/15/83 and again became able to control his behavior and actions to an acceptable degree. During course of hospitalization patient seemed to show more insight into his problems and acknowledged his need to take the prescribed medication. He was largely preoccupied however, with finding new housing, in particular a new apartment and in financial matters.... PROGNOSIS: Guarded in view of chronicity of patient's condition and his past hospitalization. Upon discharge, he was provided a two weeks supply of Haldol (30 mg. daily) and Cogentin (2 mg. daily). The appellant's 50 percent rating was maintained through January 1, 1990. Medical evidence obtained or associated with the claims file for the period between his 1983 hospitalization at ISPI and January 1990, included the reports of VA psychiatric examinations (VAX) conducted in April 1985 and April 1986, as well the report of "Social Survey" completed by the VA's Social Work Service in February 1985. The February 1985, Social Survey indicated that the appellant was adjusting reasonably well on his current psychotropic medication regimen of Haldol, 30 mg. daily and Cogentin, 2 mg. daily. It was also noted that the appellant was receiving regular outpatient counseling (once per month) for his schizophrenia at the West Side (Chicago) VA Medical Center's Mental Hygiene Clinic. The appellant denied any loose associations, tangential or circumstantial thinking; however, he continued to report frequent auditory hallucinations (2-3 times per day). His employment situation was significant for no gainful employment since February 1982, to which the VA social worker noted "[he] has no specific ideas on what to do at this time." VAXs in April 1985, and April 1986, reflected unchanged diagnoses of schizophrenia disorder, paranoid type. His presenting complaints, Haldol regimen, routine of outpatient treatment and employment status (unemployed) had remained unchanged since the February 1985, Social Survey. VARO's decision to reduce the appellant disability evaluation to 30 percent was based essentially on the report of VAX conducted in February 1990, and the report of hospitalization at ISPI in May 1989. VAX in February 1990, resulted in a diagnosis of schizophrenic disorder, paranoid type. It was also noted that he was still attending weekly therapy group meetings at the West Side VA Medical Center and that his medication regimen was Haldol, 20 mg. daily. His reported complaints were focused on difficult family matters (his sister's cancer condition and elderly mother). He indicated that he was still unemployed. On mental status examination, it was reported that his auditory hallucinations had ceased with his current Haldol medication regimen. Findings were significant for a dysphoric affect, fear of elevators and feelings of insecurity, inferiority and guilt. He was also depressed about his family situation, as indicated above. The May 1989, hospital report from ISPI reflected that he had been transferred from the West Side VA Medical Center for psychiatric evaluation following an acute alcohol and drug intoxication episode. His course of hospitalization at ISPI was described as follows: Patient was admitted to the unit in a disorganized and incoherently speaking state. He was put in full-leather restraints for about two days, and he was rapidly tranquilized with Haldol 10 mg. q.2 hrs. x4., and then the patient was started on a regular dose of 40 mg. of Haldol a day. The patient seemed to become more elucid [sic] over the next two days. Patient said part of the problem of his being hospitalized was that he was mixing alcohol and street drugs with his medication and he became disorganized and didn't really know how he got here. The patient also disclosed that he was having trouble at work. His supervisor was putting pressure on him to take a new job, and the patient started to drink more. Also, the patient seemed to disclose that part of his problem was due to having trouble with his girlfriend presently and not being able to cope with some of those problems. Patient basically did much better over the next few days and he seem[s] to respond very well to the Haldol.... Prognosis: Prognosis is poor. His Axis I diagnosis at discharge on May 11, 1989, was alcohol and opioid abuse. He was instructed to seek follow-up outpatient treatment at the West Side VA Medical Center and his discharge medication was Haldol 25 mg. daily and Cogentin 2 mg. daily. Additional medical evidence obtained and considered by VARO during the course of the present appeal included the report of VA psychological evaluation completed in February 1990, an ISPI hospital report showing a period of hospitalization in March 1991, and the report of VAX conducted in December 1991. The results of the February 1990, VA psychological evaluation were summarized as follows: The overall impression is of a client who has been diagnosed as a chronic schizophrenic for many years. With both therapy and medication, he is under fair control, but even as recently as last May [1989], he went of[f] the deep end again, and began to develop more severe symptomatology. The current evaluation further indicates the potential for emotional regression, and possibly acting out. His new-found stability remains very precarious. The client's level of confidence is shaky, and his overall reality testing is adequate, but does indicate the potential for further regression. It was further noted by the above-cited report that the appellant's attempt to pursue his professed interest in employment in the computer field could be attained through an organization like "Thresholds," which attempts to gradually ease mental patients into a more competitive work or school situations. In addition, it was recommended that he continue his regular course of outpatient therapy at the West Side VA Medical Center. The March 1991, hospital report from ISPI indicated that the appellant required inpatient psychiatric evaluation following an episode in which he set his apartment ablaze trying to melt shoe polish in his kitchen. This incident caused considerable damage to the apartment and apparently forced the appellant out into the streets. He was apparently picked up by his mother and sister and transported to ISPI. At the time of admission he denied any auditory hallucinations, any increase in anxiety or change in sleep patterns; however, he reported that he was under stress concerning the necessity of passing an up-coming examination for employment with the U. S. Postal Service. Medical history was as essentially reported above; he was continuing his outpatient group therapy at the West Side VA facility and his Haldol regimen was 15 mg. daily. His course of hospitalization was essentially unremarkable; however, he occasionally had some visual episodes of paranoid features as well as one incident of internal stimuli response. Discharge diagnosis was schizoaffective disorder and polysubstance abuse by history. His prognosis was described as fair to good with continued treatment regimen. He was provided a five day supply of Haldol, 10 mg. daily. VAX in December 1991, resulted in a diagnosis of schizophrenia disorder, paranoid type, based on the results of mental status examination and review of the entire claims file by the examining VA physician. It was noted that the appellant was continuing his above cited course of outpatient group therapy for his schizophrenia as well as his alcohol problem, and it was also noted that he remained on Haldol, 20 mg. daily. Alcohol abuse was reported as current and significant for a quart of beer per day. At the time his examination he reported that he was unemployed. (As referenced above in the May 1989, ISPI hospital report, he had been employed for nine months in 1988-89 by the U. S. Postal Service; however, he could not maintain that course of employment due to his mental condition and alcoholism). On mental status examination, findings were significant for reported auditory hallucinations and feelings of loneliness. II. Analysis The Board believes that the 50 percent disability rating for the appellant's service-connected schizophrenia, paranoid type, should not have been reduced to a 30 percent rating. Under the provisions of 38 C.F.R. § 3.344, rating agencies are charged with maintaining stable disability ratings, consistent with the law and VA regulations. In doubtful cases, the former disability rating should be maintained. Moreover, though material improvement in the physical or mental condition may be reflected, the evidence must show that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a) (1994). In this case, as fully detailed above in the Factual Background, the medical evidence reflects a current diagnosis of schizophrenia disorder, paranoid type. This diagnosis has remained unchanged with no reported remissions since 1983, when a 50 percent rating was assigned for the appellant's schizophrenia disorder. Further, the medical evidence reflects that the appellant requires regular outpatient treatment and a continuous regimen of psychotropic medication to prevent severe regressions of his mental disorder. The ISPI hospital reports dated in 1983, 1989 and 1991 clearly show that his Haldol medication must be maintained at daily dosages of 15 to 20 mg. in order to control his psychotic symptomatology. Moreover, with respect to his overall level of industrial impairment, the appellant's recent attempt to acquire and maintain employment with the U. S. Postal Service in 1988-89 failed due specifically to his schizophrenia and chronic polysubstance abuse. In view of the above findings, and together with the appellant's current complaints and extent of overall functional impairment, which has remained essentially unchanged for many years, the Board is of the opinion that the medical evidence of record does not demonstrate sustained improvement and, therefore, is insufficient to justify a reduction of the 50 percent disability rating for his schizophrenia disorder. See 38 C.F.R. §§ 3.344(a), 4.13 (1994) and Brown v. Brown, 5 Vet.App. 413, 419 (1993). Careful scrutiny of the ISPI hospital reports dated in 1983 and 1989 show no real improvement in the appellant's schizophrenia. In fact, his prognosis went from "guarded" in 1983, to "poor" in 1989. Accordingly, restoration of a 50 percent disability rating for the appellant's service-connected schizophrenia, paranoid type, is warranted, effective from January 1, 1990, the date of reduction. Based on the February 1990, VA psychological evaluation, as well as the report of recent hospitalization at ISPI in March 1991, the Board does not believe that the next higher disability evaluation (70 percent) is warranted at this time. According to the Rating Schedule, definite impairment of social and industrial adaptability caused by ratable psychotic disorders, such as paranoid schizophrenia, is rated 30 percent disabling, considerable impairment is rated 50 percent disabling, and a 70 percent rating is assigned for severe impairment, with lesser symptomatology of active psychotic manifestations. 38 C.F.R. Part 4, Code 9203 (1994). The aforementioned evidence clearly reflects "considerable" impairment due to his mental disorder, with related anti-social behavior and deviancy (drug and alcohol abuse); however, it was also reflected that his schizophrenia is fairly well controlled currently with his regimen of Haldol and outpatient treatment at the West Side VA Medical Center's Mental Hygiene Clinic. ORDER Restoration of a 50 percent rating for the appellant's service- connected schizophrenia, paranoid type, effective from the date of reduction, January 1, 1990, is granted, subject to law and regulations applicable to the disbursement of VA monetary benefits. KENNETH R. ANDREWS, JR. 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.