Citation Nr: 1218655 Decision Date: 05/25/12 Archive Date: 06/07/12 DOCKET NO. 09-16 694 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to compensation under 38 U.S.C.A. § 1151 for tardive dyskinesia, to include muscle spasms of the legs, neck, respiratory system and eyes. REPRESENTATION Appellant represented by: Karl A. Kazmierczak, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from August 1974 to October 1974. This appeal to the Board of Veterans' Appeals (Board) arises from a February 2008 rating decision of the San Diego Regional Office (RO) of the Department of Veterans Affairs (VA). In August 2011, a Board hearing was held at the RO before the undersigned Veterans Law Judge; a transcript of the hearing is of record. In November 2011, the Board sought an independent medical opinion (IME) from a private psychiatrist in relation to the Veteran's claim. That opinion was received in December 2011. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Treatment of the Veteran's schizophrenia with antipsychotic medications by VA medical personnel caused him to develop tardive dyskinesia (TD). 2. The weight of the competent and probative medical evidence indicates that the VA treatment of the Veteran with antipsychotic medication did not represent any negligence, lack of skill, error in judgment or fault. 3. The weight of the competent and probative medical evidence indicates that the VA treatment with antipsychotic medications was provided to the Veteran with his informed consent and that any deviation in informed consent procedure was minor in nature. CONCLUSION OF LAW The criteria for entitlement to compensation benefits under the provisions of 38 U.S.C.A. § 1151 have not been met. 38 U.S.C.A. §§ 1151, 5107 (West 2002); 38 C.F.R. § 3.361 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) includes enhanced duties to notify and assist claimants for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claims, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a November 2007 pre-rating letter, the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate his claim, as well as what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The February 2008 RO rating decision reflects the initial adjudication of the claim after issuance of the November 2007 letter. Although it does not appear that the Veteran received a notice letter, which provided him with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, he was not prejudiced by this omission. As the instant appeal is being denied, neither a disability rating nor an effective date is being assigned. No further notice is required. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of the service treatment records, VA treatment records, private treatment records and the December 2011 IME. Also of record and considered in connection with the appeal is the transcript of the August 2011 Board hearing, along with various written statements provided by the Veteran and by his representative on his behalf. The Board notes that no further RO action, prior to appellate consideration of the claim, is required. II. Factual Background The evidence of record shows a diagnosis of schizophrenia as early as February 1979. Also, a May 1989 discharge summary indicates that the Veteran's mother reported that he had had approximately ten prior psychiatric admissions and that he had a history of taking anti-psychotic medications, including Thorazine, Mellaril, Navane, Haldol, Trilafon and Loxitane. VA treatment records show that the Veteran sought medical treatment on April 10, 1989 for complaints of radiating headache, photophobia, chronic constant tingling of the arms, legs and head, muscle weakness and runny eyes. He was found to be hypertensive with the headaches possibly related to the hypertension. He was subsequently seen on April 13, 1989 in the psychiatric emergency unit (PEU) at the Palo Alto VA Medical Center (VAMC) for complaints of anxiety with multiple somatic complaints, including numbness in his whole body, dizziness and a rubbery feeling in his legs. At the time of the PEU assessment, the diagnosis was rule out paranoid schizophrenia but the Veteran did not wish to receive anti-psychotic medications or to be hospitalized. He was again seen at the PEU on May 1, 1989 and was put on an involuntary 72 hour hold. At the time of this admission, he reported that he disliked all medications because he felt that they caused akathisia. The Veteran apparently did start taking Navane on May 3, 1989. His mental functioning was noted to "clear rapidly" and he was found to be quite responsive to his medications. However, on May 4, 1989, he left the hospital against medical advice. Within that day, he apparently experienced a dystonic reaction and went to the San Jose, California Hospital for treatment. He was also apparently discharged from this latter hospital that same day. The Veteran returned to the VAMC on May 8, 1989 and reported that he had stopped taking the Navane because he became sweaty, shaky, had a twisted neck and was "swallowing his tongue", and that as a result, he had had to be taken by ambulance to San Jose Hospital on May 5, 1989. Subsequently, on May 22, 1989, the Veteran was admitted to the VAMC as a voluntary patient and on May 25, 1989, he was then placed on another 72 hour involuntary hold. At that time, he was noted to be agitated and hostile, with a potential for violent behavior. While being treated, the Veteran was prescribed Trilafon. On May 28, 1989, the Veteran agreed to accept voluntary treatment and he initially continued to receive the Trilafon. However, because he reported that he was experiencing side effects from the medication, including akathisia, the Trilafon was discontinued and replaced with Mellaril. He was eventually discharged against medical advice on June 19, 1989 and was provided with a prescription for Mellaril, Cogentin and a number of other non-psychiatric medications. Records from later in 1989 show that the Veteran periodically sought medical care for multiple somatic complaints, including feelings of total body numbness and nervousness. He was referred to the PEU in October 1989 but did not wish to be seen there. He was seen in the PEU in January 1990 at which time it was noted that he looked tense and that his legs were in constant motion. The Veteran reported that the leg tremors had been present since service. Also, he again reported that he did not like to take psychiatric medications because of akathisia. The examining physician noted that he was able to talk the Veteran into taking some Mellaril. He also indicated that he specifically discussed the side-effects of the medication, including tardive dyskinesia. Benadryl was also prescribed. The Veteran was subsequently seen periodically by medical and psychiatric personnel during 1990. In February 1990, it was noted that he had a moderate tremor in all extremities, which he reported having experienced for many years. On February 21, 1990, he was found to be agitated with a suggestion of auditory hallucinations and to be sleeping only one to two hours a day. He reported that Mellaril had been effective for his psychiatric symptomatology at higher doses and that he had had difficulty with Haldol, Thorazine and Stelazine. As a result, the Mellaril dose was increased to 400 mg per day. He was also prescribed Benadryl and Cogentin and it was specifically noted that the Benadryl was being prescribed to help with the akathisia. The Veteran was subsequently seen in April 1990 at which time he was found to possibly have the signs of early tardive dyskinesia, including facial grimacing and akathisia, with his knees and legs moving. The examining physician indicated that he had explained the side effects of Mellaril to the Veteran but that he had also found that the Veteran was actively psychotic. The physician noted that because the Veteran's psychiatric symptoms had substantially improved while taking Mellaril, he anticipated that the Veteran would experience psychotic decompensation if he stopped taking the medication. Consequently, the physician maintained the Mellaril prescription at 400 mg, discontinued the Cogentin and increased the Benadryl dose. A few subsequent records from the early 1990s show continued complaints related to tardive dyskinesia. A November 1990 medical record shows a notation of possible tardive dsykinesia, with the Veteran reporting that he kept swallowing his tongue and this made his jaw numb. A February 1992 clinical record shows an Axis III diagnosis of tardive dyskinesia. A May 1993 progress note shows that the Veteran reported getting tardive dyskinesia of the mouth with unpredictable attacks that sometimes affected his speech. An August 1994 progress note includes a finding that the Veteran was very unhappy about his tardive dyskinesia and wanted to know if there could be a cure for it. Physical examination showed that the facial tardive dyskinesia was very prominent. The Veteran was informed that some patients' tardive dyskinesia had been helped with clozapine. More currently, VA treatment records from 2007 and 2008 show a diagnosis of chronic dyskinesia with bradykinesia, rigidity, shaking, nausea and pain. A September 2007 VA neurology note specifically includes a finding that the Veteran's dyskinesia, bradykinesis and rigidity in his limbs were likely related to his taking multiple antipsychotic medications in the past. In a September 2010 letter, the Veteran's attorney argued that the antipsychotic medications prescribed by VA treating physicians clearly caused the Veteran's tardive dsykinesia. The attorney also contended that despite the Veteran showing clear signs of the disorder, no steps were taken to address the risk of tardive dyskinesia and the possibility that he could develop tardive dykinesia was not discussed with him. During his August 2011 Board hearing, the Veteran and his representative generally contended that the Veteran developed tardive dyskinesia as a result of taking antipsychotic medication and that the treating VA medical personnel continued to give him the medication even after it was clear that he had developed the disorder. The Veteran also contended that he was sometimes forced to take the antipsychotic medication. Additionally, he asserted that he was actually given Navane from May 1, 1989 to May 4, 1989 even though he complained the entire time of tardive dyskinesia-related symptoms (e.g. tremors, uncontrollable movements, chronic muscle spasms). In the December 2011 IME, the private psychiatrist indicated that he had reviewed the medical record. He noted that the record shows that the Veteran was guarded around physicians and refused to cooperate with them in some instances. He had been non-compliant and uncooperative in multiple instances, behavior, which was consistent with paranoid schizophrenia. Symptoms included auditory hallucinations and looseness of associations, likely responding to internal stimuli, and ideas of reference. All of these symptoms were also consistent with chronic schizophrenia, paranoid type (CPS). The psychiatrist indicated that the Veteran did develop an acute dystonic reaction to thiothixine (Navane) during one of his VA psychiatric hospitalizations and that he was also later treated with thioridazine (Mellaril). The psychiatrist commented that the standard of care for CPS is lifetime treatment with an antipsychotic medication. Often patients with CPS have no insight into the presence, nature, extent or disability caused by their illness. This appeared to be the case in the Veteran's case as he had consistently denied that he had a mental disorder, other than anxiety for which he constantly sought benzodiazepines. Because of this, he frequently did not take the prescribed antipsychotic medications, which in turn led to frequent readmissions to the hospital. It was equally clear from the record that the Veteran did have tardive dyskinesia. This was beyond a reasonable doubt due to treatment with antipsychotic medications that he received beginning with the first time he was diagnosed with a psychotic disorder. The psychiatrist noted that tardive dyskinesia (TD) is a well known and difficult to treat sequela of taking antipsychotic drugs and drugs with a similar mechanism of action, such as metoclopramide. TD can happen after one dose of a drug but is typically "Tardive" after chronic use. TD appears as repetitive and involuntary movements of the face, mouth, extremities or trunk. These include grimacing, tongue protrusion, lip smacking, "rabbit mouth", and involuntary movements of the arms or legs, which the patient sometimes tried to mask by constant brushing movements or other gestures. The psychiatrist found, however, that there was very little evidence whatsoever that the physicians or staff of the VA Medical Center involved in the care of the Veteran were negligent or careless in any way in providing that care. Review of the records revealed a patient who was drug-seeking, who consistently wanted pills and who made threats of aggression at times to obtain drugs. When these threats escalated, the Veteran was sent to a unit that was more secure. It was clear, however, that when possible, the Veteran was provided information about his status, was monitored carefully and was allowed as much freedom as his chronic mental illness would allow. Medical staff attempted on numerous occasions to develop a therapeutic alliance, which typically failed long term due to the Veteran's non-compliance with medications. The psychiatrist identified several important factors related to the Veteran's case. He indicated that abrupt cessation of antipsychotic medication (due to noncompliance) can worsen, if not actually cause, tardive dyskinesia and that the Veteran apparently abruptly stopped taking his antipsychotic medications on numerous occasions. Due to the Veteran's anxiety and consistent drug seeking behavior, he was almost always taking a benzodiazepine, which is the standard of care for the treatment of extrapyramidal symptoms (EPS) (e.g. dyskinesias and dystonias) that are more difficult to control. In addition, the Veteran was also consistently taking a benztropine (Cogentin) or diphenhydramine (i.e. Benadryl), which are also indicated for EPS. Further, when the Veteran did develop the acute dystonia from the thioxthixine, he was switched to a lower potency agent, thioridazine. The psychiatrist noted that thioridazine is less prone to resulting in EPS and is thus believed to be less prone to resulting in TD. The psychiatrist did observe that in some cases, larger than normal dosages of an antipsychotic medication were used. These dosages were higher than the guidelines suggest as a standard. However, these dosages were still within the realm of the standard of care and still within the realm of good clinical practice at the time, especially in relation to a patient displaying violent and aggressive tendencies. All of the factors mentioned by the psychiatrist pointed to his conclusion that the treating VA medical staff had not exhibited any negligence, carelessness, lack of skill or error in judgment. III. Law and Regulations The applicable version of 38 U.S.C.A. § 1151 provides, in pertinent part, that a veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C.A. § 1701(3)(A), and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151. Under the law, in order to establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the veteran's additional disability. 38 C.F.R. § 3.361(c)(1). Merely showing that a veteran received care, treatment, or examination, and that he has additional disability, does not establish cause. Id. In determining whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after such care or treatment. See 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in a veteran's additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish cause. See 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. See 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. See 38 C.F.R. § 3.361(d)(1). Informed consent is the freely given consent that follows a careful explanation by the practitioner to the patient or the patient's surrogate of the proposed diagnostic or therapeutic procedure or course of treatment. The practitioner, who has primary responsibility for the patient or who will perform the particular procedure or provide the treatment, must explain in language understandable to the patient or surrogate the nature of a proposed procedure or treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and anticipated results if nothing is done. 38 C.F.R. § 17.32(c). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(2). Pursuant to the language of the aforementioned law and regulation, section 1151 claims for additional disability are treated similarly to claims for service connection. See Jones v. West, 12 Vet. App. 383 (1999); Boggs v. West, 11 Vet. App. 334 (1998). Hence, to establish entitlement, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of incurrence or aggravation of an injury as the result of hospitalization, medical or surgical treatment, or the pursuit of a course of vocational rehabilitation under Chapter 31 of title 38, United States Code; and (3) medical evidence of a nexus between that asserted injury or disease and the current disability. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). IV. Analysis In the instant case, the evidence clearly shows that the Veteran does have an additional disability, tardive dsykinesia. It also shows that the cause of this disability was the antipsychotic medication prescribed by VA treating medical professionals. This is most clearly emphasized by the opinion of the December 2011 private psychiatrist, who specifically found that the disorder resulted from the treatment with antipsychotic medications the Veteran received beginning with the first time he was diagnosed with a psychotic disorder. The evidence does not show that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in prescribing the medication, however. To the contrary, after a thorough review of the record, the December 2011 private psychiatrist specifically concluded that VA medical staff had not exhibited any negligence, carelessness, lack of skill or error in judgment in treating the Veteran with the antipsychotic medications. In drawing this conclusion, the psychiatrist specifically noted that the standard of care for treating schizophrenia is lifetime treatment with an antipsychotic medication; that VA physicians prescribed appropriate medications to attempt to control the Veteran's extrapyramidal symptoms; that when possible the Veteran was provided with as much information about his status, was monitored carefully and was allowed as much freedom as his chronic mental illness would allow for; and that when the Veteran did develop acute dystonia from thiothixine (i.e. Navane), he was appropriately switched to thioridazine (Mellaril), a lower potency agent, believed to be less prone to resulting in TD. The psychiatrist also noted that although the Veteran was at some points given larger dosages of antipsychotic medication than those suggested as standard by treatment guidelines, these dosages were still within the realm of the standard of care and still within the realm of good clinical practice at the time, especially in relation to a patient displaying violent and aggressive tendencies. The Veteran has also asserted that there were times he was given antipsychotic medication against his will. Generally, the evidence of record does to support this assertion. Instead, it generally indicates that the Veteran was compliant with taking the prescribed medication while he was being treated at a VA facility and that he often tended to stop taking the prescribed medication after he was discharged. Additionally, the Board notes that in California, medication may be legally administered against a person's will when an emergency situation is present so it is possible that the Veteran may have received involuntary medication in such a situation at some point during his many years of treatment, if he was perceived by medical staff to be an imminent danger to himself or others. See California Welfare and Institutions Code § 5332(e). In any case, even assuming the Veteran was given such involuntary medication, there is no indication that it was not appropriately administered (i.e. in a non-emergent situation). Further, although the Veteran has contended that VA treatment staff continued to give him Navane from May 1 to May 4, 1989, even though he was specifically complaining of TD symptoms, the record appears to indicate that he only took Navane from May 3rd to May 4th, at which time he was discharged from the hospital against medical advice. Subsequently, he was switched to Mellaril. Moreover, in regard to both the claims of receiving medication against this will and the claim of continued treatment with Navane, once again, the December 2011 private psychiatrist, after a comprehensive review of the record, found that VA medical staff had not exhibited any negligence, carelessness, lack of skill or error in judgment in treating the Veteran with the psychiatric medications and there are no contrary medical opinions of record. This uncontradicted conclusion weighs against a finding that the Veteran inappropriately continued to receive Navane or that he received any inappropriate injections of involuntary psychiatric medication during the time frame covered by the medical record. Moreover, although the Veteran alleges that VA was generally at fault in continuing to prescribe him antipsychotic medications, as a layperson, his allegations concerning the appropriate medical standard of care are entitled to minimal probative weight. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The evidence also tends to indicate that the Veteran was specifically informed of that TD was a potential side effect of taking the antipsychotic medications in question. In this regard, the January 1990 VA physician specifically noted that he had discussed the side-effects of Mellaril with the Veteran, including TD. Similarly, in April 1990, the treating physician noted that he specifically explained the side effects of Mellaril, including that the Veteran could be exhibiting early signs of TD, prior to recommending that the Veteran continue to take Mellaril to avoid psychiatric decompensation. Some of the earlier documentation of record pertaining to administration of the medication does not include such explicit notations. However, the record contains clear notations that treating VA medical staff was aware that the Veteran had had the dystonic reaction to Navane and that he had been experiencing the type of extrapyramidal symptoms that may be associated with TD. It also shows that once aware of this problem, the treating medical staff stopped treating the Veteran with Navane and instead used other medications, including Mellaril, which has been found to potentially have a lower likelihood of causing TD. In this context, the Board finds it likely that the staff would have provided the Veteran with specific information concerning the risk that the continued use of the antipsychotic medications could result in TD. Also, given that the record shows that the Veteran was suffering from acute bouts of psychosis during the time in question and given that he was generally noted to be a poor historian, the Board does not find credible his assertion, made through his attorney, that the risk of TD was not explained to him. Accordingly, the weight of the evidence indicates that this risk of TD was appropriately explained to the Veteran by VA medical staff. Moreover, even assuming the risk of TD was not explained in every instance where antipsychotic medication was prescribed, this represents only a minor deviation in the informed consent process. Notably, the failure to advise a patient of a forseeable risk can be considered a minor, immaterial deviation under the applicable regulation if a reasonable person in similar circumstances would have proceeded with the medical treatment even if informed of the forseeable risk. McNair v. Shinseki, 25 Vet. App. 98 (2011). Notably, the December 2011 private psychiatrist specifically indicated that lifetime treatment with antipsychotic medications was the standard of care for treatment of the Veteran's CPS and there is no indication in the record that there was any alternative to these medications available to the Veteran to prevent debilitating psychiatric decompensation. Faced with such a debilitating prospect, the Board finds that a reasonable person would continue to take the medication as prescribed even in the face of a significant risk of developing chronic TD. The Board sympathizes with the Veteran's current predicament as his TD is a debilitating residual of the antipsychotic medications that were available to prescribe to him during the time frame in question. However, the Board must appropriately apply the governing legal authority in each case. In this case, the weight of the evidence is against a finding that the TD was a result of any carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the medical staff. The weight of the evidence is also in favor of a finding that VA prescribed the antipsychotic medications to the Veteran with his informed consent and that any deviation in informed consent procedure was minor in nature. Accordingly, the preponderance of the evidence is not in the Veteran's favor and compensation under section 1151 for tardive dyskinesia must be denied. Gilbert, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 for tardive dyskinesia, to include muscle spasms of the legs, neck, respiratory system and eyes, is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs