BVA9502678 DOCKET NO. 93-11 949 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an evaluation in excess of 10 percent for post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD G. Wm. Thompson, Counsel INTRODUCTION The veteran had active military service from December 1967 to December 1969. He was in Viet Nam from July 1968 to June 1969; the available records do not show any combat awards or citations. This appeal arises from the February 1993 Department of Veterans Affairs (VA) Montgomery, Alabama, Regional Office (RO) rating action that granted service connection for PTSD, and assigned a 10 percent evaluation. Statements made by the veteran in August 1992 could be construed as a claim for service connection for bilateral foot disability. That matter is not intertwined with the issue on appeal, and the RO's attention is directed to the statement for action deemed appropriate. REMAND The Board of Veterans' Appeals (Board) notes that in the course of this appeal the veteran has indicated that his ongoing headaches are a symptom of the recently diagnosed PTSD. In this regard the Board notes that he was provided a separate examination for headaches in October 1992, with what appears to be a diagnosis of tension headaches, and reference to follow-up and further evaluation. There was no separate rating for headaches in the February 1993 rating action and it is not clear whether headaches are part and parcel of the service-connected post traumatic stress disorder or a separate disability. If headaches are part and parcel of the PTSD, then rating of that disorder should have been deferred pending the reported follow-up and further evaluation. If the headaches are not part of the PTSD, then there should be a rating action delineating that disability. The veteran reports treatment at the VA Hospital in Birmingham, Alabama, in 1969 or early 1970. The RO apparently requested such records in August 1992 but the Board can see no response in the claims folder. Further, the psychiatric examination diagnosis in October 1992 was post traumatic stress disorder-severe. The March 1993 Statement of the Case reveals that the primary evidence used in evaluating the veteran's psychiatric disability was the October 1992 psychiatric evaluation. The statement of the case concluded that the veteran did not meet the schedular requirements for an increased evaluation. This case is remanded for actions as follows: 1. The RO should follow up on the attempt to secure records of treatment for the veteran in 1969 or 1970 at the VA Medical Center Birmingham, Alabama. 2. The RO should secure all records associated with any follow-up and evaluation for the veteran's headaches. If the follow- up and evaluation have not been performed, it is to be accomplished. Using these records, the RO should then formally determine whether the headaches are part of the PTSD or a separate disability entity. 3. The Board notes that the veteran in his April 1993 substantive appeal made reference to seeing a doctor and a "counselor." The RO, with the help of the veteran should attempt to secure all records associated therewith. He should also be permitted to submit or identify any other evidence in support of his claim. Medical evidence or opinion concerning treatment for the disability at issue or any psychiatric problems after service would be helpful. Evidence identified should be obtained by the RO. 4. The RO should arrange for the veteran to undergo complete psychological testing by the VA, with applicable subscales, in accordance with the Physician's Guide for Disability Evaluation Examinations. A complete personality profile should be included. 5. Following completion of the foregoing, the veteran is to be scheduled for a comprehensive VA psychiatric examination. This study must be conducted in accordance with the VA Physician Guide for Disability Evaluation Examinations. The claims folder must be made available to and reviewed by the examiner prior to the requested study. If post traumatic stress disorder is found, the symptoms which support the diagnosis should be specifically itemized. In addition, the examiner should be requested to characterize the overall degree of psychiatric impairment resulting from PTSD, in accordance with the terminology used in the rating schedule, such as "mild," "definite," "considerable," or "severe." The examiner must assign a Global Assessment of Functioning (GAF) score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (3d ed. rev., 1987), and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examination does not include all test reports, special studies or opinions requested, appropriate corrective action is to be implemented. When the foregoing development has been completed, the claim should be reviewed by the RO. If any determination remains adverse to the veteran, a supplemental statement of the case should be prepared and the veteran and his representative should be given a reasonable period of time for reply. No action is required of the veteran until he receives further notice. THOMAS J. DANNAHER Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).