Citation Nr: 1745346 Decision Date: 10/12/17 Archive Date: 10/19/17 DOCKET NO. 13-33 279 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to January 4, 2016, and in excess of 50 percent thereafter, for undifferentiated type schizophrenia. 2. Entitlement to an initial compensable rating for porphyria cutanea tarda (PCT). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Adamson, Counsel INTRODUCTION The Veteran served on active duty from January 1970 to August 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the San Juan, Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA). The RO awarded service connection for undifferentiated type schizophrenia by way of the September 2012 rating decision on appeal. An initial 30 percent rating was assigned. A March 2013 rating decision was then issued awarding service connection for PCT and assigning an initial noncompensable rating. The Veteran perfected an appeal as to the initial ratings assigned for both disabilities. The Board remanded both issues on appeal in June 2015 for additional evidentiary development. Following the remand development, the RO issued a rating decision in February 2016 and awarded a 50 percent rating for the undifferentiated type schizophrenia, effective January 4, 2016, the date of the examination. As 50 percent is not the highest possible rating for this disability and the Veteran has not indicated satisfaction with the rating assigned, the appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. Throughout the pendency of this claim, the Veteran's undifferentiated type schizophrenia has caused occupational and social impairment with reduced reliability and productivity. 2. At no time during the pendency of this claim did the Veteran's undifferentiated type schizophrenia cause either occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 3. At no time during the pendency of this claim did the Veteran's PCT impact at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of the exposed areas affected, or require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during a twelve month period. CONCLUSIONS OF LAW 1. The criteria for an initial rating 50 percent rating for undifferentiated type schizophrenia are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, DC 9411 (2016). 2. The criteria for an initial compensable rating for PCT are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.118, DC 7815 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veteran was provided adequate notice regarding the claims decided herein by way of the letter dated in August 2012. All appropriate development to obtain the Veteran's pertinent, available service treatment records and post-service medical records from the San Juan VA Medical Center (VAMC) has been completed. The Veteran has not identified any private or other VA healthcare facilities from which he receives treatment for his claimed disabilities. Also, the Veteran was afforded appropriate and adequate VA examinations related to his skin and psychiatric disorders, most recently in November 2015 and January 2016, respectively. The Veteran has not suggested and the record does not show a worsening in these disabilities since that time. The Board finds no reason to remand these issues for additional examinations. Thus, the Board will move forward to decide the claims based upon the evidence of record. Finally, the Board notes that neither the Veteran, nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). General Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2016). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2016). In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). VA must consider all favorable lay evidence of record. 38 U.S.C.A. § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly considered the lay evidence offered by the Veteran, in the form of correspondence to VA, and the medical evidence cited below. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2016) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities on appeal. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability under review. Undifferentiated Type Schizophrenia The Veteran's schizophrenia has been rated under 38 C.F.R. § 4.130, Diagnostic Code 9204. The criteria for rating mental disorders generally, and schizophrenia specifically, are listed under the General Rating Formula for Mental Disorders ("General Rating Formula"). 38 C.F.R. § 4.130. Prior to August 4, 2014, the nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities was based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. During the course of this appeal, VA amended the General Rating Formula and its regulations to remove outdated references to the DSM-IV, including Diagnostic Code 9204. See 79 Fed. Reg. 149, 45094 (Aug. 4, 2014). The use of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (also known as "DSM-5") applies to all claims received by VA or pending before the AOJ on or after August 4, 2014, but does apply to claims that have been certified for appeal to the Board or are pending before the Board as of that date, even if such claims are subsequently remanded to the AOJ. See id.; see also 80 Fed. Reg. 53, 14308 (Mar. 19, 2015). Here, the AOJ certified the Veteran's appeal to the Board in January 2014, thus the DSM-IV is for application. See January 28, 2014 VA Form 8. The General Rating Formula provide that a 50 percent evaluation is warranted where there is 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 (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code," and, if so, the "equivalent rating will be assigned." Id. A veteran may only qualify for a given initial or increased rating based on mental disorder by demonstrating the particular symptoms associated with that percentage in the rating criteria, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Although a veteran's symptomatology is the primary consideration in assessing a disability rating based on a mental disorder, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas" for that rating. Id.; 38 C.F.R. § 4.130. The Veteran filed his claim for service connection for a neuropsychiatric disorder in February 2012. Shortly prior to the claim, the Veteran sought initial care in the San Juan VAMC in November 2011. The behavioral nursing screening at that time noted a past medical history including anxiety, nervousness, psychiatric hospitalization, and a suicide attempt, although the date of this history was not indicated. The Veteran's thought process, thought content, judgment and insight were all normal. His memory was deemed poor for recent events. There were no hallucinations and no suicidal or homicidal ideation at this time. The report of a psychiatric consultation the same month indicated the Veteran's mood was euthymic and his affect restricted, but his thought processes were logical and coherent, and there were no delusions or hallucinations. The Veteran reported poor sleep and irritability. The psychiatrist diagnosed him has having depression and assigned a GAF score of 70. A course of preventive counseling was prescribed. In an April 2012 psychiatric clinic note, a history of a single suicide attempt in the early 1980's was noted. The Veteran also reported a history of psychiatric hospitalizations in the 1970's. At the time of the examination, he reported feeling fairly well, with occasional sadness and recently feeling his mind was going blank. He reported improved sleep. The symptoms were otherwise the same as prior evaluations. Symptoms were consistently reported in May 2012. However, in July 2012, the Veteran's symptoms seemed to worsen. At this time, his treating psychologist noted he was referred by his primary care physician due to episodes of disorientation. The Veteran reported sometimes forgetting what he is talking about, and he reported the onset of these symptoms three to four months prior. The Veteran also reported feeling depressed and he indicated that he hears voices that give him orders, although he confirmed he was neither suicidal, nor homicidal. The psychologist noted the Veteran was hostile during testing and that his mood was depressed. The clinician declined to refer the Veteran for a complete neuropsychological evaluation due to his refusal to complete the tasks for evaluation on that day. The Veteran was then afforded a VA examination in August 2012. Because the Veteran's claim included a contention that he had posttraumatic stress disorder (PTSD), the examiner first assessed whether the diagnostic criteria for PTSD were met. The examiner determined that the Veteran's symptoms do not meet the diagnostic criteria for PTSD under the DSM-IV criteria. Rather, the examiner found the Veteran had schizophrenia, undifferentiated, and deemed it in remission. The examiner stated that no other psychiatric disorder was present. The examiner found the Veteran to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. At the time of the examination, the Veteran reported being married and working as a self-employed auto mechanic for the past twenty years. He reported his days involved working, helping around the house, going for walks and sometimes to church, as well as watching television. The examiner reported that the Veteran exhibited suspiciousness, but no other symptoms of psychiatric disorder were noted. Because the Veteran's records show a 1982 diagnostic impression of schizophrenia, undifferentiated type, the 2012 examiner diagnosed schizophrenia, undifferentiated, in remission. The examiner assessed the Veteran as having a GAF score of 50 to 60. October 2012 and December 2012 clinical notes show symptoms consistent with those in the VA examination report and prior to July 2012. His mood was noted as sad in October 2012 and the increase in sadness was related to the death of his brother. A February 2013 clinical note shows the Veteran reporting feeling stable about his mental condition, but noting an increase in sleep disturbance and nightmares over the prior month. There was no evidence of perceptual disturbance, and no report of suicidal or homicidal thoughts, or hallucinations. Recent memory was noted as impaired, but his memory was otherwise intact. In January 2014, the Veteran reported to his VA primary care physician that he experienced poor sleep and irritability and he presented with a sad mood. No other symptoms were noted and the GAF score was again assessed as 70. April 2014 psychiatry progress notes show consistent symptoms. However, in April 2014, the Veteran underwent a psychologist evaluation in relations to treatment for chronic pain in a rehabilitation clinic. At that time, he reported sadness, anger, anxiety, irritability, physical aggression, isolation and insomnia. At this time, the Veteran again reported hearing voices of aggressive command. The Veteran described these as sporadic, and confirmed having none at the time of the examination. The Veteran's memory and attention were noted as fair. December 2014 clinical notes related to rheumatology treatment indicate the Veteran did not present a depressed mood or any suicidal or homicidal ideas. In February 2015, the Veteran reported continued experience with trouble sleeping and irritability. The Veteran reported feeling stable, and continuing to experience feelings of sadness. The clinician observed the Veteran to be adequately dressed, with logical and coherent communication. The Veteran's affective responses were less restrictive and he reported no delusions and no voices. GAF score was assessed as 70 at that time. The Veteran was most recently afforded a VA examination in January 2016. The examiner confirmed the presence of schizophrenia and depression and noted the inability to differentiate between the symptoms. This examiner assessed the Veteran as having occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran was accompanied by his wife and reported positive relationships with this wife and adult children. The Veteran denied the presence of auditory or visual hallucinations at that time, but reported a history of such symptoms. The examiner confirmed the presence of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss such as forgetting names, directions or recent events, a flattened affect, and disturbances of motivation and mood. The examiner noted the Veteran's eye contact was good, but his speech was sometimes hard to understand. The examiner noted the Veteran's reported history of memory deficiency, but was unable to verify such at the time of the examination. In sum, the Veteran's psychiatric symptoms throughout the pendency of the claim have included ongoing depression, irritability and sleep disturbance. Fairly regularly, the clinical notes indicated impairment in short term memory. More than once, the Veteran reported forgetting things and feeling his mind was going blank at times. The Veteran also reported positive relationships with his wife and children throughout, but no relationships with anyone outside of his family, despite the Veteran's ongoing work as an auto mechanic. The Board finds these symptoms to be indicative of impairment of short term memory, disturbances in mood, and difficulty establishing and maintaining effective work and social relationships. Each of these is listed under the criteria for a 50 percent rating under the General Rating Formula. The Board also finds these symptoms to have been consistent throughout the pendency of the Veteran's claim. Although the Veteran does not have every symptom listed under the criteria for a 50 percent rating, that is not what is required. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). The Board finds the severity of his symptoms throughout the pendency of this claim most closely approximate occupational and social impairment, with reduced reliability and productivity. Thus, a 50 percent rating is warranted for the entire period on appeal. However, the evidence does not suggest the presence of suicidal ideation, obsessional rituals, illogical, obscure or irrelevant speech, panic, depression affecting the Veteran's ability to function independently, impaired impulse control, spatial disorientation, neglect of personal appearance or hygiene, difficulty in adapting to stressful circumstances, or an inability to establish and maintain effective relationships. Thus, the Veteran does not demonstrate the symptoms associated with a 70 percent rating at any time during the period of this claim. Further, there is no indication of gross impairment of thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting of self or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation or own name. The Board indeed recognizes the Veteran's report of auditory hallucinations twice during the pendency of the claim, in July 2012 and April 2014. In April 2014, he described these to occur sporadically. While present, the hallucinations cannot be described as persistent. Thus, the Veteran does not demonstrate the symptoms associated with a 100 percent rating at any time during the period of this claim. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, even affording the Veteran full competence and credibility, the evidence simply does not show entitlement to a higher rating than that assigned herein under any applicable diagnostic code. Consideration has been given to assigning staged ratings; however, at no time during the period in question has the Veteran's psychiatric disorder warranted more than the 50 percent rating being assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record with regard to the disability at issue. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Porphyria Cutanea Tarda The Veteran's PCT is noncompensably rated under 38 C.F.R. § 4.118, Diagnostic Code 7815. He filed his claim in February 2012. Under Diagnostic Code 7815, a noncompensable rating is warranted if less than five percent of the entire body or exposed areas are affected, and no more than topical therapy was required during the past 12-month period. A 10 percent rating is warranted if at least five percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or; intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, was required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted if 20 to 40 percent of the entire body, or 20 to 40 percent of exposed areas are affected, or; systemic therapy, such as corticosteroids or other immunosuppressive drugs, were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted if more than 40 percent of the entire body, or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, was required during the past 12-month period. A May 2012 VA dermatology clinic note shows the presence of scattered lesions, including purpuric patches, on the Veteran's forearms. The clinician noted these to be senile purpura and explained that this is a benign skin condition related to aging, in that the skin is thinning with fragility and capillary rupture. The clinician explained that this condition is exacerbated by aspirin use. The dermatologist noted the Veteran's reported history of PCT and specifically stated that there were currently no lesions of PCT. In September 2012, the Veteran's VA primary care physician noted the Veteran's reported history of PCT, but again only noted a current diagnosis of senile purpura. There was no indication of a use of medication to treat either. October 2012 dermatology notes also indicated purpura on the face and arms, with an additional indication of rosacea, but no suggestion of the presence of lesions related to PCT. January 2013 VA primary care notes show the Veteran complaining of itchy patches on his face, arms and legs. January 2013 dermatology clinic notes show treatment for lesions on his forearms and lower extremities, which were described as macules and patches of purpuric/violaceous scattered lesions. There was also mild erythema on the nose and mid-cheeks, with no postules or papules. The clinician noted the Veteran's report of PCT, but indicated that a urine test would need to be conducted to confirm it. The diagnosis at this time was purpura of bateman and rosacea. Labs were ordered for urine collection to confirm PCT. There is no indication in the record that the Veteran reported for these labs. The January 2013 clinician made note that the Veteran had previously not reported for the requisite lab work, so the Board must presume that he again did not follow up. The Veteran underwent a VA skin diseases examination in November 2013. The Veteran described having PCT since the prior year, although, as noted above, the treatment the prior year was for a different skin disorder. The Veteran described purpuric lesions with erosions on his forearms, which he reported resolved spontaneously. The Veteran confirmed no history of phlebotomy or oral drug as treatment for PCT. The examiner confirmed the use of oral and topical medications for rosacea, but there is no suggestion of treatment for PCT. On physical examination, the examiner noted the presence of senile purpura on the forearms, bilaterally, and specifically noted that there is no evidence of active PCT. This VA examiner also noted the referral for a urine collection in January 2013 to confirm the presence of PCT. The examiner noted that the request remains in a pending state and that no diagnosis of PCT could be made without the urine test. The Board reviewed the remaining clinical records and there is no indication of any additional dermatology clinic visits. August and September 2014 primary care notes show no lesions present and no dryness. A January 2015 primary care note is also negative as to any skin abnormality. Most recently, the Veteran was afforded a VA skin diseases examination in November 2015. The Veteran again reported he was diagnosed with PCT, but then again described the symptoms as including very sensitive skin on his legs, arms and face, which is very thin and breaks easily with minor traumas. He reported that he is only taking aspirin (ASA 81 mg daily) and that his only treatment for his skin is to avoid traumas. The examiner noted another prescription for prednisone, but indicated that this was for arthritis. The examiner's physical examination of the Veteran revealed no evidence of the presence of any visible skin condition and no eruptions, vesicles/bullae, or hematomas. The only abnormality noted by the examiner was skin on the arms appearing xerotic and thin, which is consistent with the earlier findings of senile purpura. There is no additional evidence in the record relevant to this claim. In sum, the evidence of record throughout the pendency of this claim shows no active presence of PCT, thus no coverage of at least five percent of the entire body, and no treatment of any sort. There is simply no basis upon which to assign a compensable rating for this service-connected skin disorder. The Veteran's appeal is, therefore, denied. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, even affording the Veteran full competence and credibility, the evidence, including his lay statements, simply does not show entitlement to a compensable rating for the disability at issue. Consideration has been given to assigning staged ratings; however, at no time during the period in question has the Veteran's PCT warranted a compensable rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record with regard to the disability at issue. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER An initial evaluation 50 percent, but no higher, for undifferentiated type schizophrenia is granted, subject to the rules and regulations governing the payment of VA monetary benefits. Entitlement to an initial compensable evaluation for PCT is denied. ____________________________________________ V. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs