TWO-YEAR PRESUMPTIVE PERIOD FOR DISEASE OF

PSYCHOSIS

WEDNESDAY, JANUARY 16, 1952

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE OF THE COMMITTEE ON VETERANS' AFFAIRS,

Washington, D. C. The subcommittee met at 10 a. m., the Honorable Joe L. Evins, presiding.

Present: Mr. Evins (presiding), Mr. Jones of North Carolina, and Mr. Devereux.

Mr. EVINS. The committee will come to order.

The subcommittee has met this morning to consider the bill H. R. 5891, which seeks to provide a flat 2-year presumptive period for veterans who develop the disease of psychosis.

A similar bill was considered in the first session of the Eightysecond Congress, but was amended by the Senate in such a form as to provide only for priority for hospitalization and out-patient treatment. Compensation specifically was not included as one of the provisions of this bill, which subsequently became Public Law 239.

Service organizations are united in the belief that psychosis should be treated on the same basis as other diseases covered by a presumptive period; that is, that it should entitle the veteran to priority in admission to hospitals and at the same time provide compensation.

Without objection I will insert at this point a copy of the bill, together with the Veterans' Administration report thereon, and a description of the disease as found in the Merck Manual.

(The above material to be inserted is as follows:)

[H. R. 5891, 82d Cong., 2d sess.]

A BILL To amend the veterans regulations to establish for certain persons who served in the Armed Forces a further presumption of service connection for an active psychosis

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That the second last proviso of subparagraph (c) of paragraph I, part I, Veterans Regulation Numbered 1 (a), as amended, is hereby amended by inserting after the words "multiple sclerosis" the words "or active psychosis."

SEC. 2. The Act of October 30, 1951 (65 Stat. 694; 38 U. S. C., ch. 12, note) is hereby repealed.

[H. R. 5892, 82d Cong., 2d sess.]

A BILL To liberalize the basis for establishing wartime service connection for active tuberculosis, the psychoses, and multiple sclerosis

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That the second last proviso of subparagraph (c) of paragraph I, part I, Veterans Regulation Numbered 1 (a), as amended;

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is hereby amended to read as follows: "Provided further, That active tuberculosis, multiple sclerosis, or a psychosis developing a 10 per centum degree of disability or more within three years from the date of separation from active service, shall, in the absence of affirmative evidence to the contrary, be deemed to have been incurred in or aggravated by active service:".

Hon. JOHN E. RANKIN,

VETERANS' ADMINISTRATION, Washington 25, D. C., January 14, 1952.

Chairman, Committee on Veterans' Affairs,

House of Representatives, Washington 25, D. C.

DEAR MR. RANKIN: Reference is made to your request for a report by the Veterans' Administration on H. R. 5891, Eighty-second Congress, a bill to amend the Veterans Regulations to establish for certain persons who served in the Armed Forces a further presumption of service connection for an active psychosis. The purpose of the bill is to amend the Veterans Regulations to provide that an active psychosis developing a 10-percent degree of disability or more within 2 years from the date of separation from active service shall, in the absence of affirmative evidence to the contrary, be deemed to have been incurred in or aggravated by active service.

Veterans Regulation No. 1 (a), part I, paragraph I, subparagraph (c), as amended, provides generally that a chronic disease (other than active pulmonary tuberculosis and multiple sclerosis) becoming manifest to a degree of 10 percent or more within 1 year from the date of separation from active service, as defined in subparagraph (a) of said regulation, shall be considered to have been incurred in or aggravated by such service, notwithstanding there is no record of evidence of such disease during the period of active service, if the person suffering from such disease served 90 days or more in the active service, except where there is affirmative evidence to the contrary, or evidence to establish that an intercurrent injury or disease which is a recognized cause of such chronic disease has been suffered between the date of discharge and the onset of the chronic disease, or the disability is due to the person's own willful misconduct. With respect to active pulmonary tuberculosis a 3-year presumptive period is provided and for multiple sclerosis a 2-year period. The presumptions in this paragraph are applicable to veterans of wars specified in part I of the mentioned regulation and, because of the provisions of Public Law 28, Eighty-second Congress, May 11, 1951, to persons who shall have served in the active service on or after June 27, 1950, and prior to such date as shall thereafter be determined by Presidential proclamation or concurrent resolution of the Congress.

The list of chronic diseases set forth in the mentioned statutory regulation (as amended by Public Law 748, 80th Cong., and subsequent legislation) does not specifically include "active psychosis," but such a mental disorder has long been recognized by the Veterans' Administration as a chronic disease and included as such by administrative regulation.

H. R. 5891 is similar to H. R. 320, Eighty-second Congress, as passed by the House of Representatives May 1, 1951, except that the latter bill contained a 3-year presumptive period. As you are aware, H. R. 320 was amended in the Senate to provide a conclusive presumption of service connection for an active psychosis developing within 2 years from the date of separation from active service in World War II, but only for the purpose of hospital and medical treatment, including out-patient treatment, authorized under laws administered by the Veterans' Administration. The bill was passed by the Congress in this form and approved as Public Law 239, Eighty-second Congress October 30, 1951. Under this law it is not necessary that the veteran have 90 days' service for the presumption to attach and willful misconduct is not a bar. H. R. 5891 proposes a repeal of Public Law 239, and substitutes a 2-year rebuttable presumption of service connection for the purpose of hospital and medical treatment, as well as for all other purposes. The 90 days' service requirement would be for application, as well as the misconduct rule. In view of the relatively short period since the enactment of Public Law 239, no worth-while information is available at this time regarding the number of cases benefited thereby. There is definite medical substantiation that the time of onset of a psychiatric disorder, whether a psychosis or a psychoneurosis, is not the only criterion of the cause or causes. Determination of causation, or etiology, of a psychosis in an individual is to be gained by an over-all psychiatric evaluation of that

particular person. Psychosis may result from any one of a number of factors, such as an inherent or hereditary defect. The proposed legislation, however, would establish a statutory presumption, which grants a presumption of fact, of uniform application, that a manifestation of a psychosis at any time up to 2 years after separation is necessarily related to the facts or circumstances of wartime military service or service on or after June 27, 1950.

The present regulatory presumptive period does not preclude the granting of direct service connection for a psychotic condition when first diagnosed more than 1 year after separation from service when the evidence of record is deemed adequate to warrant a finding of service connection. In such cases, under the directive contained in Public Law 361, Seventy-seventh Congress, December 20, 1941, "where a veteran is seeking service connection for any disability due consideration shall be given to the places, types, and circumstances of his service as shown by his service record, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence." Public Law 361 further provides:

"In the case of any veteran who engaged in combat with the enemy in active service with a military or naval organization of the United States during some war, campaign, or expedition, the Administrator of Veterans' Affairs is authorized and directed to accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by service in such war, campaign, or expedition, satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of such veteran: Provided, That service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary."

The 1-year presumptive period for the service connection of a chronic disease, previously covered by regulation based upon sound medical judgment, was in 1933 incorporated in Veterans Regulations promulgated under Public No. 2, Seventy-third Congress. In 1948 Congress specified certain diseases which, among others, should be deemed chronic, but did not extend the uniform 1-year presumptive period (Public Law 748, 80th Cong.). It was not until 1950 that an exception to the general rule was made in the case of active pulmonary tuberculosis (Public Law 573, 81st Cong.), and in 1951 a further presumption was authorized in the case of multiple sclerosis (Public Law 174, 82d Cong.). As previously indicated, in 1951 the Congress also extended the presumptive period for an active psychosis for the limited purposes of hospital and medical treatment. The committee will, no doubt, wish to give careful consideration to the problem of whether the extension of the presumption for psychosis for all purposes will be urged as a precedent for extending the presumptive period for many other chronic diseases.

The Veterans' Administration has no available data upon which to base an estimate of the number of veterans of World War II who incurred a disease of psychosis developing a 10-percent degree of disability or more within 2 years from date of discharge from World War II service, nor would it be possible to forecast the number of persons having service after June 27, 1950, who might be eligible to benefits in the future. However, there are now over 9,000 veterans of World War II in receipt of disability pension because of non-service-connected psychosis, permanently and totally disabling, many of whom would probably be eligible for the benefits of the bill. An unknown number of psychotic cases having a disability less than total in degree, and therefore not pensionable under existing legislation, would also qualify for service connection under H. R. 5891. Payments of disability compensation range from $15 to $150 monthly under percentage gradations of disability from 10 to 100 percent with additional allowances for dependents in those cases where the disability is rated 50 percent or greater. Furthermore, enactment of H. R. 5891 would entitle an unknown number of dependents of deceased veterans to monthly payments of death compensation from $75 upward to widows and children, and payments to dependent parents. Monthly death pension from $42 upward, depending upon the number of children, would be payable in certain cases to widows and children in cases of deaths not due to service. In addition to the foregoing, vocational rehabilitation under Public Law 16, Seventy-eighth Congress, as amended, would be available in certain cases as the result of establishment of service connection. It is not possible to furnish an estimate of the cost of the bill, if enacted, in view of the many unknown and variable factors. However, it is apparent that the cost would be very substantial.

Due to the urgent request of the committee for a report on this measure, there has not been sufficient time in which to ascertain from the Bureau of the Budget the relationship of the proposed legislation to the program of the President. Sincerely yours,

O. W. CLARK (For Carl R. Gray, Jr., Administrator).

[Excerpt from the Merck Manual, eighth edition]

THE PSYCHOSES

Any mental disorder, including the psychoneurotic reactions, involves the total personality and extends to its depths. In the psychoses, however, the disturbance is of such magnitude that the mind is distorted more or less in entirety. The conscious portion of the ego no longer functions efficiently in its role of recognizing the source of at least some of the impulses that reach and pervade it. In one degree or another, therefore, it accepts as environmentally authentic material that actually is ideational. Thus the psychotic displays inability to correct his misconceptions about what is real and what is unreal.

Except that it includes the senile, presenile, and arteriosclerotic psychoses, this section deals only with those psychoses that are presumed to arise solely from intrapersonality conflict: schizophrenia, paranoia, and paranoid_conditions, the manic-depressive psychoses, and the involutional psychoses. Numerous other causes for psychoses exist, such as specific infections, including syphilis, epidemic encephalitis, acute chorea, and tuberculosis, epidemic cerebrospinal, or other forms of meningitis. Other causes are alcoholism, convulsive disorders (e. g., epilepsy), brain tumor, metabolic disease, trauma, and drugs and other exogenous toxins. This last group of substances includes mercury, manganese, carbon disulfide, carbon monoxide, opium and its derivatives, bromides, cocaine, the barbituric acid group, peyote, mescaline, belladonna, chloral, and paraldehyde. Many of these reactions are adequately described elsewhere in the Manual (q. v.). Delirium is a temporary psychosis. Patients with mental deficiency or a so-called psychopathic personality may develop a psychosis, often displaying atypical manic-depressive or schizophrenic reactions. There is little doubt that in most instances the "psychopath" is as he is because of his environment, and he and the feebleminded individual may become psychotic because of continuing environmental stress.

SCHIZOPHRENIA

(Dementia praecox)

The term “schizophrenia” means splitting of the mind, which is more descriptive of this condition than early or precocious dementia, as implied by the term "dementia praecox." Dementia, an irreparable impairment of cognitive and intellectual functions, does not occur with this condition. Rather, schizophrenia may be considered as a psychobiologic reaction that arises on the basis of personality inadequacies, and results in an inability to meet the demands of adult adjustment. The reaction is characterized by progressive withdrawal from contact with persons and activities in the environment and regression to a childlike or infantile type of feeling or acting. An inferior affective capacity is one of the important results when the personality becomes disorganized or split in schizophrenia. This is displayed as an inadequate and inappropriate emotional response to situations, and represents a deterioration of emotional expression. Etiology, Incidence, and Predisposing Factors

Schizophrenia constitutes from 15 to 20% of the first admissions to public mental hospitals, and 60% of their permanent population. The age of onset ranges from childhood to late middle life, but the psychosis is most frequent in adolescence or early adult life.

No constant or characteristic structural or biochemical change has yet been established in this condition. That the causes of schizophrenia are to be searched for in the individual's basic personality and the extent or limit of its adaptive power is the most generally accepted concept today. Childhood conditioning experiences, intrapsychic conflicts, persistent but consciously rejected instinctive

urges and drives, feelings of insecurity or guilt, and other long-standing troublesome problems and frustrated purposes, in one combination or another, must be considered as potent precipitating forces.

Schizophrenia often represents only an extreme expression of the patient's previous schizoid type of temperament and personality. The contrasting poles of this type are sensitiveness on the one hand, and dullness or coldness on the other. The sensitive schizoid is timid and shy, self-conscious, perhaps stubborn and suspicious, and often dissatisfied; he is constantly being wounded. Reserved and socially inept, he may find in books a substitute for human companionship. The subjects he chooses usually are not of concrete objective type, but rather of abstract nature. He frequently is ambitious, conscientious, particular, and perfectionistic. Other schizoids lack the finer sensibilities of the group above. Many of these lack spontaneity and appear colorless personalities. This group varies from kindly, honest, but emotionally dull, unsociable and uncompromising individuals, to cold, reserved, and callous types.

Prodromal Stage

Frequently there is no abrupt transition, but rather an insidious change in mood and outlook. Long-existing disharmonies of thought, habit, and interest become accentuated. The individual may seem preoccupied, be considered lazy, and may begin to believe others are talking about him or do not care for him. Such ideas of reference are common. He may become restless, taciturn, or ill at ease, yet appear unworried about odd mannerisms that make their appearance. Some ruminate on sexual topics and others on hypochrondriacal ideas. At this stage the conflicts are not greatly disguised and may often he discovered without difficulty.

The Manifest Psychosis

An apparent poverty and increased disharmony in the feeling tone of the individual now may appear. However, some patients show not an absence of mood, but a prevailing one, such as euphoria or depression. But these moods will generally be found to have little or no relation to conscious mental content and none to external circumstances. Not infrequently, the opposite emotional response will be evoked by an idea or experience—an emotional dissociation or disconnection.

Since schizophrenia may be considered as a reaction characterized by introversion, or the direction of the individual's energy and interests upon himself and his subjective life, and by the expression of rejected material through symbolism, one expects and finds no disturbance in consciousness or memory, and so none of orientation. The patient's intellect is inert rather than impaired.

The affect, or feeling tone, having been withdrawn from conscious mental assets and attached to complexes and other material in the unconscious, and being therefore inaccessible to the individual, the patient often feels' changed throughout. He may come to feel he observes, as a spectator, his own actions which seem to him impersonal and mechanical. Such states of depersonalization are not uncommon. In his attempt to rationalize this sense of the loss of the limits of his own personality, his nihilistic ideas may increase until he feels he is dead, or no longer has a body, or that there is no world.

Paralogia, a condition in which the reply to one's question indicates that it has been understood, although the answer because of defective reasoning, is erroneous, is due to the dereistic thinking which occupies much of the schizophrenic's attention. Symbols and associations, molded by unconscious instinctive drives and affects, rise into consciousness and constitute dereistic, or dreamlike thinking, a pleasurable thinking that disregards realistic, logical, and scientific concepts and thus tends to falsify reality.

Often, the dominant ideational content of the schizophrenic is delusional in nature. The delusions tend to center around themes of persecution, or grandiosity, and of sex. While these often appear grotesque, apparently they always are specific and adapted to the peculiar psychologic needs of the individual.

Normally, associations and ideas progress with logical connection on to ultimate completeness of thought, but in the schizophrenic they may be so fragmented and shortened, or otherwise distorted, as to appear illogical. In early schizophrenia, a flight of ideas may occur; this later tends to develop into incoherence. Neologisms, or coined words, probably represent extreme condensations and symbolizations of complexes, conflicts, and other unconscious material highly charged with affect. Blocking, or sudden cessation of a thought-and its verbal expression-is one of the hallmarks of schizophrenia, and presumably

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