Citation Nr: 20022480 Decision Date: 04/01/20 Archive Date: 04/01/20 DOCKET NO. 13-05 882 DATE: April 1, 2020 REMANDED Entitlement to a rating higher than 50 percent for service-connected schizophrenic reaction, for substitution and/or accrued benefits purposes, is remanded. Entitlement to special monthly compensation (SMC) based on a need for aid and attendance, for substitution and/or accrued benefits purposes, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), for substitution and/or accrued benefits purposes, is remanded. REASONS FOR REMAND The Veteran had active duty from July 1948 to September 1948; he died in November 2009. The appellant is his surviving spouse and has been substituted as the appellant in this appeal. The appellant testified before a Veterans Law Judge (VLJ) of the Board in March 2016. By a March 2018 letter, the appellant was informed that the VLJ who conducted the hearing was no longer employed by the Board. In March 2018, the appellant indicated she did not want another hearing. In a May 2018 decision, the Board denied entitlement to a rating higher than 50 percent for service-connected schizophrenic reaction, and denied entitlement to SMC based on a need for aid and attendance. The appellant then appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2019 Joint Motion for Remand (Joint Motion), the Court, the parties (the Veteran and the Secretary of VA) requested that the Board decision be vacated and the issues remanded. In an August 2019 order, the Court granted the Joint Motion and remanded the claims for action consistent with the terms of the Joint Motion. In February 2020, the appellant's representative filed a Veteran's Application for Increased Compensation Based on Unemployability (VA Form 21-8940), contending that a TDIU was warranted during the Veteran's lifetime. A request for a TDIU, whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of the claim for an increased rating for the service-connected disabilities listed above. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the Board finds the issue of entitlement to TDIU was raised by the appellant's representative; therefore, the issue is added to the issues on appeal. 1. Entitlement to a rating higher than 50 percent for service-connected schizophrenic reaction purposes is remanded. In the July 2019 Joint Motion, the parties agreed that the Board did not adequately analyze the frequency, severity, duration, and functional effects of the Veteran’s symptoms from schizophrenic reaction in its May 2018 decision. The case was remanded for such analysis. The Board was instructed to consider the medical evidence of record that attributed the Veteran's cognitive impairment to his schizophrenia. A review of the claims file reflects that during the last several years of his life, the Veteran was diagnosed with dementia and Alzheimer’s disease in addition to schizophrenia. The appellant and her representative contend that the Veteran's schizophrenic reaction caused dementia, or that the impairment from Alzheimer’s disease and dementia cannot be differentiated from his schizophrenic reaction. See February 2020 brief. She also contends that the Veteran's substance use disorders were secondary to his service-connected schizophrenic reaction. A remand is necessary to obtain a retrospective VA medical opinion concerning the severity of the Veteran’s schizophrenic reaction during the period from March 2000 to his death in November 2009. See Chotta v. Peake, 22 Vet. App. 80, 85-86 (2008). The examiner should also to opine as to whether it is possible to separate the effects of the service-connected schizophrenic reaction from non-service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam) (When it is not possible to separate the effects of the service-connected disability from a non-service-connected disability, such signs and symptoms must be attributed to the service-connected disability.) Moreover, the Board finds that there is a significant discrepancy between a recent private psychologist’s opinion and the contemporaneous private and VA examiners’ opinions concerning the severity of the Veteran’s schizophrenic reaction throughout the appeal period. Specifically, there are substantial differences between a private examiner’s January 2020 private opinion that the Veteran’s schizophrenic reaction produced total occupational and social impairment from March 2000 to November 2009, and the contemporaneous VA and private medical records. For example, a September 1999 private medical record shows that the examiner opined that the Veteran was oriented to time, place and person, recent and remote memory were intact, and he had normal judgment, insight, mood, and affect. In June 2000, VA psychological testing was strongly suggestive of early stages of a dementing illness; the examiner stated that the results were suggestive of a primary degenerative dementia. Subsequent medical records related some of his symptoms to Alzheimer’s disease and dementia. In June 2001, he was diagnosed with dementia, probably Alzheimer’s type. A January 1999 private magnetic resonance imaging (MRI) was performed to ascertain if he had had a stroke. The diagnostic impression was mild to moderate generalized atrophy, mild periventricular white matter, chronic small vessel ischemic change and mild to moderate pontine small vessel chronic ischemic change, and a small remote lacunar infarction in posterior right basal ganglia. In October 2005, a private physician, Dr. P., opined that the Veteran had paranoid schizophrenia, and cognitive impairment from this disorder. VA medical records dated in January 2006 show that his problem list included Alzheimer’s disease, presenile dementia, and organic brain syndrome not elsewhere classified. In September 2008, a VA psychiatrist diagnosed vascular dementia, and said that his cognitive impairment had progressed since his last visit. The psychiatrist stated that they needed to rule out Alzheimer’s disease mixed with vascular changes, and that the Veteran had a dementia behavior disturbance. The examiner also indicated a diagnosis of rule out mood disorder secondary to an underlying medical condition, i.e. brain changes. Based on a review of the claims file, the VA examiner should provide, if possible, a retrospective opinion concerning the severity of the Veteran’s psychiatric disorder in order to reconcile the significantly divergent opinions in this case. 2. Entitlement to SMC based on a need for aid and attendance is remanded. 3. Entitlement to a TDIU is remanded. The issues of entitlement to SMC and a TDIU are deferred as they are inextricably intertwined with the above remanded issue. The matters are REMANDED for the following action: 1. Obtain a retrospective VA medical opinion from an appropriate clinician to determine the severity of the Veteran's service-connected schizophrenic reaction from March 2000 until his death in November 2009. The examiner should review the claims file, including the January 2020 report of a private psychological evaluation provided by Dr. B., which was based, in part, on an interview with the Veteran's surviving spouse. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to provide an opinion regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected schizophrenic reaction alone. If the examiner cannot distinguish the symptoms due to the service-connected schizophrenic reaction from the symptoms of non-service-connected dementia or substance abuse disorder, the examiner should so state. If it is not possible to provide any of the requested retrospective opinions, the clinician must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). A complete rationale should be provided for all opinions and conclusions. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. L. Wasser, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.