Citation Nr: 9900120 Decision Date: 01/05/99 Archive Date: 01/12/99 DOCKET NO. 97-08 485 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased rating for psychosis, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Military Order of the Purple Heart ATTORNEY FOR THE BOARD T. Mainelli, Associate Counsel INTRODUCTION The appellant had active service from October 1986 to June 1990. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a November 1996 rating decision, in which the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA) declined an increased evaluation for a nervous disorder. The Board remanded this case in December 1997, and following completion of the requested development, the case has been returned for further appellate review. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in essence, that her psychiatric disability, which is manifested by occasional psychotic episodes triggered by stressful circumstances and non- compliance with her use of neuroleptic medications, interferes with her daily life and industrial adaptability. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the appellant'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 appellant’s claim for an increased rating for her psychosis. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the appellant’s claim for an increased rating has been developed. 2. The appellant’s psychiatric disability, diagnosed as psychosis not otherwise specified, is manifested principally by minimal psychiatric symptoms with occasional psychotic episodes triggered by stress and non- compliance with her neuroleptic medication. 3. The appellant’s psychosis results in no more than mild- to-moderate difficulty in social or occupational functioning or no more than definite impairment of social and industrial adaptability. CONCLUSION OF LAW The criteria for an increased rating for psychosis have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.130, 4.132, Part 4, Diagnostic Code 9210 (1996- 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the appellant’s claim is “well grounded” within the meaning of 38 U.S.C.A. § 5107(a). That is, she has presented a claim which is plausible. See Proscelle v. Derwinski, 2 Vet.App. 629, 631 (1992). Furthermore, she has undergone recent VA psychiatric examination and the medical evidence of record is sufficient to decide this case. The Board accordingly finds the duty to assist her, mandated by 38 U.S.C.A. § 5107, has been satisfied. The appellant was medically discharged from the Army in June 1990 due to a psychotic disorder. By means of a rating decision dated in July 1990, the RO granted her claim for service connection for atypical psychosis, and assigned the 30 percent disability rating currently in effect. In July 1991, the appellant was admitted to Georgia Regional Hospital stemming from an incident in which she set a fire outside her apartment complex in a fit of anger. She claimed that her in- laws had beaten her prior to her husband’s departure to Saudi Arabia, however, her in- laws reported that she had been non- compliant with her anti- psychotic medications. In September 1991, she was transferred to the Augusta, Georgia VA Medical Center (VAMC). Initial mental status evaluation was significant for findings of sad mood, flat affect and thought content positive for delusions of reference in sexual matters. At times during her hospital stay, she showed loose associations and paranoid delusions about her husband and possibly her in- laws. Her treatment included prescriptions of Haldol and Cogentin, as well as individual and group psychotherapy. Upon discharge, her prognosis was considered good as long as she remained on Haldol and continued psychotherapy. In April 1992, the RO assigned a total disability rating (100 percent) for her period of hospitalization, and continued the assignment of the 30 percent rating thereafter. VA outpatient treatment records, dated from May 1992 to August 1993, show that the appellant’s psychiatric condition was clinically evaluated as stable. In March 1993, her attending physician noted that she was capable of attending cosmetology class, but her physician also noted that her condition needed to be closely followed in case she decompensated due to the increased pressure from school. VA mental disorder examination, dated in August 1993, revealed that her psychiatric disability, diagnosed as paranoid type schizophrenia with lay history of auditory and visual hallucinations, seemed to be in fair to good remission while she was taking Haldol. A September 1994 VA outpatient treatment report reveals that the appellant reported hearing voices, and appeared anxious, tearful and paranoid. It was noted that she had stopped taking her medications. On VA Compensation and Pension (C&P) examination, dated in October 1994, she reported occasional delusions and hallucinations, both auditory and visual in nature, and complained that her medication made her drowsy. She also reported periods of “violent behavior” since her 1991 hospitalization. Mental status examination was unremarkable, and diagnosis was of chronic, paranoid type schizophrenia which resulted in a severe degree of social and industrial impairment. On VA mental disorders examination, dated in August 1995, the appellant reported difficulty in sleeping. She denied delusions or hallucinations, and now viewed her previous episodes of such incidents as ego alien. She felt that her medication and treatment was helping her, and she felt motivated to continue her treatment. Remainder of examination was unremarkable. VA outpatient treatment report, dated in September 1995, noted that the appellant manifested some symptomatology of guarding and preoccupation, and reported continued active positive and negative schizophrenic symptoms. Her complaint of symptoms, as well as her use of medication which helped stabilize her condition, caused impairment of her daily functioning. In January 1996, she reported the occurrence of auditory hallucinations since she had run out of medication. She also reported legal problems stemming from a psychotic episode during which time she stole some items from a store. However, her psychotic episodes subsided once she resumed taking her medication. VA inpatient treatment report, dated in July 1996, shows that the appellant was admitted for auditory hallucinations and feelings of increased anger and stress. She had progressively become more depressed, and was having severe difficulty with her daily routine. She was unsure of why she had these feelings, though she felt that stressful events might have triggered them. She reported no obvious stress in her life, but she did have problems at work and financial problems associated with the purchase of a new home. The voices in her head told her that “she can do whatever she wants,” and she attributed this voice as responsible for her previous arrest for petty theft. Initially, she was treated by restarting her prescription of Haldol. However, psychological testing appeared to indicate that the appellant had alexithymia which may have been mistaken for psychosis. Testing also revealed borderline intellectual functioning. Accordingly, her prescription of Haldol was discontinued, and she was to be followed by the mental health clinic to monitor her progress. Diagnosis was of adjustment order, not otherwise specified, and history of psychosis. VA outpatient treatment report, dated in October 1996, reveals that the appellant was doing well without her medications. She denied hearing voices, and used stress exercises when stressed and uptight. However, on December 20, 1996, she sought treatment for auditory hallucinations. She was pregnant and was under pressure at work. The voices in her head told her that she was possessed by the devil, and that she was pregnant with triplets. Her prescription of neuroleptics (Haldol) resumed. She was admitted to hospitalization on December 26, 1996, with complaint of insomnia, anorexia, chronic fatigue and feelings of guilt with regard to the financial stresses her disease brought upon the marriage. During her stay, her auditory hallucinations gradually diminished to the point where they no longer occurred. She was discharged on February 2, 1997. It was noted that she became psychotic when she was removed from the neuroleptics in the fall. Her Global Assessment of Functioning (GAF) was scored as a 40 on admission, and a 65 at discharge which was the highest level of functioning during the past year. In March 1997, the RO assigned a total disability rating for her period of hospitalization, and continued the assignment of the 30 percent rating thereafter. VA discharge summary, dated in September 1997, reveals that the appellant was admitted for auditory hallucinations. She reported increased marital and financial stress. She complained of crying spells, decreased energy, fatigue and anhedonia. She denied feeling suicidal, but indicated that the voice she heard did want her to kill herself. On mental status examination, there was evidence of psychomotor retardation and there was poor eye contact. Her affect was depressed, and mood was congruent but the affect was somewhat blunted. She was questionably suicidal and had depressive thoughts. There were no tactile or visual hallucinations, looseness of associations, ideas of reference or delusions. Sensorium and intellectual functioning was generally intact, however, there did seem to be difficulty with general information. Insight and judgment were fair. Initially, she was placed on suicide watch and prescribed Zoloft to help with her depressive thoughts. Her Haldol prescription was also renewed. Within a week, she reported that the voices in her head were minimal and back to baseline. She was discharged as capable of returning to pre- hospital activity or employment. Her GAF score was 60. On VA mental disorders examination, dated in July 1998, the appellant reported that she was well- stabilized on her medications which included Haldol, Zoloft, Cogentin and Benadryl. However, she often felt as if she no longer needed her medication at which time she rapidly decompensated resulting in bizarre behavior and severe paranoia with hallucinations. Presently, she only reported mild paranoia, and denied any other psychotic symptoms. She indicated that her psychiatric disability caused her to become unemployable because the added stress of working caused her to forget to take her medication. On mental status examination, she was alert and oriented times three. There was no psychomotor agitation or retardation. Her mood was described as fair, and her affect was mildly restricted. Her speech was normal rate and volume and goal directed. There was no formal thought or content disorder. She denied any auditory, visual or tactile disorders. Her memory and concentration were slightly impaired, but this symptomatology may have been related to her documented borderline intellectual functioning. Her insight and judgment were described as good now that she was controlled on medication. It was the examiner’s opinion that she suffered from some psychotic disorder, but it was unclear whether or not her condition was truly a schizophrenic paranoid type or psychosis secondary to depressive disorder. Therefore, diagnosis was of psychosis disorder not otherwise specified. Presently, she had only minimal psychiatric symptoms, however, secondary to past history, she decompensated quickly resulting in hospitalizations. Her GAF score was 65. The severity of the appellant's psychiatric disability is assessed for VA compensation purposes by application of the criteria set forth in VA’s Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4. In November 1996, new regulations were issued with respect to the criteria to be considered in mental disorder cases. “[W]here the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant should ... apply unless Congress provided otherwise or permitted the Secretary of Veterans Affairs to do otherwise and the Secretary did so.” Karnas v. Derwinski, 1 Vet.App. 308, 313 (1991). Pursuant to Karnas, the Board finds that the appellant is entitled to have her claim reviewed under the regulations in effect both prior to and after November 1996. Under the current regulations in effect, the appellant is currently in receipt of a 30 percent rating under Diagnostic Code 9210 for psychotic disorder, not otherwise specified (atypical psychosis), manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self- care, and conversational normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly of less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events.) A 50 percent rating is warranted for 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Under the regulations in effect prior to November 7, 1996, a 30 percent rating for atypical psychosis, under Diagnostic Code 9210, was warranted where there was definite impairment of social and industrial adaptability. A 50 percent evaluation was warranted for considerable impairment of social and industrial adaptability. According to the most recent VA mental disorder examination, dated in July 1998, the appellant experiences “minimal psychiatric symptoms” when she is compliant with her neuroleptic medications. She manifests mild paranoia, and mildly restricted affect. She also manifests some impairment of memory and concentration, although it appears that such impairment is due to her borderline intellectual functioning. For the most part, her psychomotor functioning, insight, speech, and thought processes are intact. When she is non- compliant with her medications or under stress, she rapidly decompensates quickly resulting in auditory hallucinations and hospitalizations. With these factors in mind, the most recent psychiatric assessment of her psychological, social and occupational functioning (GAF score) was consistent with some mild-to-moderate psychiatric symptoms with some-to- moderate difficulty in social or occupational functioning. Other recent GAF scores have indicated moderate difficulty in social and occupational functioning. Based upon the foregoing, the Board finds, by a preponderance of the evidence, that the occupational and social impairment due to her psychosis is such that, under the regulations promulgated in November 1996, the appellant is not entitled to an increased rating. It is also the Board's opinion that, under the criteria in effect prior to November 7, 1996, the appellant is not entitled to an increased schedular rating. Once again, in considering the appellant’s psychiatric disability, the Board notes that, for the most part, she exhibits minimal psychiatric symptoms. Even accounting for her occasional psychotic episodes, her overall psychological, social and occupational functioning (GAF score) is consistent with some- to moderate difficulty in social or occupational functioning. After analyzing the symptomatology due to her psychosis, and her recent treatment history, the Board finds, by a preponderance of the evidence, that her psychosis causes no more than definite social and industrial impairment. Accordingly, an increased rating for her psychosis is not warranted under the criteria in effect prior to November 1996. The evidence in this case is not so evenly balanced so as to allow application of the benefit of the doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 4.3 (1998). (CONTINUED ON NEXT PAGE) ORDER An increased rating for psychosis is denied. NANCY I. PHILLIPS Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), 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, 102 Stat. 4105, 4122 (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. - 2 -