Citation Nr: 1322480 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 09-19 018A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial rating higher than 10 percent for hypochondriasis to include cold intolerance. (The issue of entitlement to service connection for residuals of pneumonia will be the subject of a separate decision.) REPRESENTATION Veteran represented by: Barbara J. Cook, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from January 1949 to June 1952. This matter comes to the Board of Veterans' Appeals (Board) on appeal of rating decision in August 2007 of a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for hypochondriasis to include cold intolerance (previously defined as psychogenic cold intolerance) and assigned a 10 percent rating effective in April 2002. In October 2007, the Veteran appealed for a higher rating for the disability, and in May 2009 the RO issued a statement of the case. The Veteran perfected his appeal to the Board by filing a substantive appeal in June 2009. In January 2013, the Veteran appeared at the RO and testified at a videoconference hearing conducted by the undersigned Veterans Law Judge sitting at the Board's offices in Washington, DC. A transcript of the hearing is of record. After the hearing, the Veteran's attorney representative in February 2013 submitted additional evidence in the form of a private medical report dated in January 2013, which was accompanied by a waiver of initial RO consideration of the evidence in accordance with 38 C.F.R. § 20.1304. Also, the Veteran's attorney in March 2013 notified the Board by letter of errors contained in the transcript of the January 2013 hearing, mostly in regard to misspellings and one error concerning a correction from "mustn't" to "must" relative to the presence of hypochondriasis symptoms. All have been taken into consideration. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is REMANDED to the RO. REMAND In regard to evaluating his service-connected hypochondriasis to include cold intolerance, the Veteran contends that during his combat experiences in Korea he was exposed to extreme cold temperatures and suffered cold injury. He maintains that ever since then he has suffered with symptoms of cold intolerance or cold sensitivity problems. He asserts that his symptoms pre-dated his diagnosis of diabetes and that they were not related to any lead toxicity that was suggested from his post-service occupation as a typesetter for a newspaper. In a February 2013 statement, the Veteran's attorney argues that given the findings of cold injury related to service in a private medical report added to the file, the Veteran's service-connected disorder should be evaluated as 30 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7122, based on his cold injury symptoms. After his hearing in January 2013, the Veteran submitted a medical report dated in January 2013, which was prepared by David Randolph, M.D., who evidently reviewed extensive service and post-service medical records supplied by the Veteran. Based on his review of the records, Dr. Randolph opined the following: that the Veteran as likely as not suffered injury from cold exposure during service; that diabetes and lead poisoning do not produce cold insensitivity; that there was evidence of peripheral neuropathy-type symptoms prior to the Veteran's diagnosis of diabetes in 1992; that lead poisoning/toxicity (as was previously suggested from his post-service occupation as a typesetter for a newspaper) was not a likely explanation for his neurological symptoms; that the VA examiners (of April 2004 and October 2006) did not provide clear, cogent explanations as to the Veteran's subjective symptom complaints that were consistent with a chronic cold injury exposure (e.g., arthralgia or joint pain, cold sensitivity, nail abnormalities, locally impaired sensation, numbness, tissue loss, color change, hyperhidrosis, and X-ray abnormalities); and that an electrodiagnostic study may be helpful in diagnosing his cold injury. The conclusions drawn by Dr. Randolph are inconsistent with those of the VA examiners in April 2002 and October 2006. In April 2002, the Veteran complained of continuing numbness and tingling of the hands and feet. The examiner diagnosed psychogenic cold intolerance and stated that there was no objective evidence for underlying neurologic vascular or rheumatologic abnormality but that the Veteran was an insulin-dependent diabetic which may be contributing to some of his current neuropathic symptoms. In October 2006, the VA examiner diagnosed cold avoidance with no evidence of Raynaud's phenomenon or actual cold intolerance (stating that this was an internal perception of coldness without vascular constriction or actual cooling of the extremities). The examiner remarked that the Veteran's symptoms of cold sensation and numbness and tingling in the extremities when exposed to cold began in 1962, many years after service, and stated that the Veteran did not sustain a discrete cold injury while in the service but was instead exposed to field conditions during the wintertime and the general discomfort of being cold. The examiner further found that the Veteran developed symptoms of a definite autonomic dysregulation after 10 years as a typesetter after service and that his symptoms were consistent with a peripheral neuropathy that has been noted in the literature in association with chronic occupational and organic lead exposure. He added that the Veteran also had evidence of diabetic peripheral neuropathy. In light of the foregoing, prior to deciding the issue of whether a higher rating is warranted for the Veteran's service-connected mental disorder that includes cold intolerance, it is necessary to reconcile the various medical findings to determine whether or not the Veteran actually has a physical disability related to cold injury in service, and if so, to discern the current nature and level of severity of his mental disorder. In that regard, it is notable that in a March 2008 decision, the Board denied the Veteran's claim of service connection for residuals of cold injury to the hands and feet, and then the U.S. Court of Appeals for Veterans Claims affirmed the Board's decision on that matter in a January 2010 Memorandum Decision. The Veteran's claim for a higher rating for hypochondriasis, however, is intertwined with the issue of cold injury. According to the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)), hypochondriasis is a somatoform disorder involving a preoccupation with the idea that one has a serious disease based on the person's misinterpretation of bodily symptoms. Stated another way, the disorder is an overwhelming fear or anxiety that one has a serious disease despite health care providers finding no evidence of an illness. Here, the Veteran has recently submitted medical evidence that appears to support his belief - which was not previously substantiated through VA examinations - that he in fact has a cold injury related to service. If so, then the nature of the Veteran's currently diagnosed hypochondriasis should be re-examined, and re-classified if warranted. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Afford the Veteran a VA neurological examination to determine whether or not he has any cold injuries to include cold injury affecting his upper and lower extremities. The claims file must be made available to the examiner for review. All necessary tests and studies should be accomplished, to include electrodiagnostic studies (nerve conduction studies) as appropriate. All clinical findings should be set forth in detail in the report. For any current diagnosed cold injury, the examiner should describe its anatomical location and severity (i.e., the presence or absence of any arthralgia or joint pain, cold sensitivity, nail abnormalities, locally impaired sensation, numbness, tissue loss, color change, hyperhidrosis, and X-ray abnormalities). The examiner is also asked to reconcile the various conclusions reached by the VA examiners and Dr. David Randolph. The VA examiner in April 2002 diagnosed psychogenic cold intolerance and stated that there was no objective evidence for underlying neurologic vascular or rheumatologic abnormality (he suggested the Veteran's diabetes may be contributing to some of his current neuropathic symptoms). The VA examiner in October 2006 diagnosed cold avoidance with no evidence of Raynaud's phenomenon or actual cold intolerance (he found the Veteran's current complaints were not related to any cold injury). Dr. Randolph in January 2013 opined that the Veteran has a cold injury that as likely as not is related to exposure to extreme cold during service in Korea. 2. Following completion of the foregoing, if, and only if, the VA neurological examination results in a diagnosis of actual cold injury, the Veteran should be afforded a VA psychiatric examination to re-examine the current nature of his service-connected hypochondriasis to include cold intolerance. The examiner should indicate whether a diagnosis of hypochondriasis is currently supported in light of the recent medical evidence added to the file. The claims file must be made available to and reviewed by the examiner, and a full rationale should be provided for all opinions expressed. The examiner should provide accurate and fully descriptive assessments of all psychiatric symptoms, and in particular should comment upon the frequency or severity of any symptoms related to hypochondriasis, if currently present. The examiner should also enter a complete multiaxial evaluation, and assign a Global Assessment of Functioning (GAF) score, together with an explanation of what the score represents in terms of the Veteran's psychological, social, and occupational functioning. A complete rationale for all opinions must be provided. 3. Thereafter, readjudicate the claim currently on appeal. If the benefits sought in connection with the claim remain denied, the Veteran and his representative should be provided with a supplemental statement of the case and an appropriate time period within which to respond. The case should then be returned to the Board for review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of the Veteran's appeal. 38 C.F.R. § 20.1100(b) (2012).