BVA9502022 DOCKET NO. 92-11 051 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUE Entitlement to service connection for a chronic acquired psychiatric disability, to include post-traumatic stress disorder. ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran served on active duty from August 1963 to December 1973. He was in Vietnam from October 1965 to October 1966. His principal duty assignment was as a baker. This appeal arises from a November 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which denied entitlement to service connection for PTSD. In March 1993 the case was remanded by the Board of Veterans' Appeals (the Board) for further development. As a result of that development, entitlement to nonservice-connected pension benefits was granted in a July 1993 rating decision. The case is again before the Board for appellate consideration. REMAND The initial question before the Board is whether the veteran has submitted a well-grounded claim as required by 38 U.S.C.A. § 5107. The United States Court of Veterans Appeals (the Court) has held that a well-grounded claim is one which is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78 (1990). In addition, in Tirpak v. Derwinski, 2 Vet.App. 609 (1992), the Court held that a claim must be accompanied by evidence (emphasis in original). In this case, the available medical records which reflect a diagnosis of PTSD, and the veteran's statements alleging stressors in service, are sufficient to conclude that his claim is well-grounded. Preliminary review indicates that the current record, and the evolving case law from the Court, mandate a further remand. The first requirement to support a diagnosis of PTSD is a "stressor." Under the case law noted below, the existence of a "stressor" is a factual determination to be made by adjudicators. In other words, the existence of an event or events in service is not a medical question. If adjudicators concede the existence of the claimed event or events, however, the question of whether any such event is adequate to cause PTSD is a medical question. In this case, specific details regarding any events the veteran alleges he experienced in Vietnam that could constitute a "stressor" have not been confirmed. The veteran's principal duty assignment while in Vietnam was as a baker, but he has claimed that he was exposed to combat. However, the recollections which are available are vague at best. For example, he refers to recollections of the time when he had to help remove bodies of downed airmen from a C-130 which crashed about 50 miles from his base at Cam Ranh Bay. He identified one deceased individual as a close friend, who he identified as Sergeant King. However, from records available to the Board, it does not appear that any Air Force sergeant named King died in Vietnam between 1965 and October 1966. The veteran's military personnel records indicate that from October 1965 to November 1965 he was a baker with the 6256th Support Squadron, at Cam Ranh Bay. From November 1965 to December 1965, he was a baker with the 6256th Forward Service Squadron at Cam Ranh Bay. During the remainder of his tour in Vietnam he was a baker with the 12th Service Squadron at Cam Ranh Bay. No information regarding the activities of any of those units is of record. Under 38 C.F.R. § 3.304(f) (1993), service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed inservice stressor. In addition, VA's Manual M21-1 contains specific procedures for VA to follow in evaluating claims for service connection for PTSD. Manual M21-1, Part VI, Para 7.46(e), (f) (Dec. 21, 1992). In Zarycki v. Brown, 6 Vet.App. 91 (1993), the Court set forth procedures for VA to follow in adjudicating claims for service connection for PTSD. The Court concluded that the statutory and regulatory criteria provided a framework in which the evidence necessary to establish the occurrence of a recognizable stressor during service to support a claim of entitlement to service connection for PTSD will vary depending on whether or not the veteran was "engaged in combat with the enemy." Where it is determined, through recognized military citations, or other supportive evidence, that the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, the veteran's lay testimony regarding claimed stressors must be accepted as conclusive as to their actual occurrence and no further development for corroborative evidence will be required, provided that the veteran's testimony is found to be credible and "consistent with the circumstances, conditions, or hardships of such service." (emphasis added.) 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(d), (f) (1994); Manual M21-1, Part VI, Para. 7.46(e), (f). If VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor, unless it is substantiated by service records. Id. The Court further held that even if it is found that there was a stressful event in service, it must still be determined whether that stressful event was of sufficient gravity to support a diagnosis of PTSD as required in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, (3d. ed. 1987) (DSM-III-R). The essential feature of PTSD is "a psychologically distressing event that is outside the range of usual human experience." The most common traumata involve a threat to one's life, a threat to the lives of one's friends, or seeing another person who has recently been seriously injured or killed as the result of an accident or physical violence. Id. at 247, 248. The Court emphasized, however, that mere service in a combat zone, in and of itself, was insufficient to support a diagnosis of PTSD. In West v. Brown, 7 Vet.App. 70 (1994), the Court commented that a "significant feature of PTSD requires that the sufficiency of the stressor be clinically established." In other words, medical evidence is required to determine whether the claimed events are sufficient stressors to support a diagnosis of PTSD. The current posture of the record does not establish that the appellant "engaged in combat with the enemy." The appellant is not shown to have received one of the citations specified in 38 C.F.R. § 3.304(f), or other combat awards appropriate to his branch of service. As noted above, even if the record contained evidence that the appellant "engaged in combat with the enemy," his accounts would still have to be reviewed to determine if they were credible and consistent with the circumstances, conditions and hardships of his service. Furthermore, the case law from the Court points to the unmistakable conclusion that if the adjudicators do not find that an event claimed as a "stressor" existed in service, any medical examination on the question of whether an individual has PTSD due to service would be pointless. In addition to the fundamental problem of the existence of a "stressor" or "stressors" in service, there are further factual matters should be addressed on Remand. The medical evidence of record discloses varying psychiatric diagnoses, including post- traumatic stress disorder (PTSD). The veteran was recently accorded an examination by a VA psychiatrist for PTSD purposes in May 1993. At that time, the examiner expressed the opinion that the veteran had a personality disorder which, along with his history of alcohol dependence, was likely more of a factor in his ongoing problems than any of his other psychiatric diagnoses "or his military service in Vietnam." Nevertheless, the examiner noted that it was "possible" that the veteran had mild symptoms of PTSD from his time in Vietnam. The record also indicates that during hospitalization by VA in August 1989, the veteran reported that in 1974 he "went to Muskogee and Oklahoma City" for the same thing as now. From that time until the 1989 hospitalization, he reported that he had not had any further psychiatric treatment. However, the records regarding any treatment in 1974 are not in the claims folder. Further review of the record also indicates that the veteran has reported receiving ongoing treatment at the Fayetteville, Arkansas, VA Medical Center for PTSD purposes. However, at the time of his mental health clinic visit in September 1993, the most recent report of record, the only impression was bipolar mood disorder. He was to return on October 18, 1993. The report of that visit, if indeed it took place, is not of record. In light of the above discussion, the Board REMANDS the case for the following development: 1. The RO should contact the veteran and request that he provide the names and addresses of any health care providers, other than VA who have treated him for a psychiatric disability, to include PTSD and specify the approximate dates of treatment, if possible. Then, after necessary authorization is obtained from the veteran, the RO should obtain copies of any treatment records, not already of record, for the veteran from the health care providers identified. Of particular interest are any records pertaining to treatment in Muskogee and Oklahoma City, Oklahoma, in 1974. The RO should also obtain and associate with the claims file all outpatient treatment records from the VA Medical Center in Fayetteville, Arkansas, from July 1993 to the present. 2. The RO should request from the veteran a statement containing as much detail as possible regarding the alleged stressful events to which he was exposed in service. The veteran should be asked to provide specific details of the claimed stressful events during service, such as dates, places, detailed descriptions of the events, his service units in Vietnam, duty assignments and the names, ranks, unit of assignment and any other identifying information concerning any OTHER individuals involved in the events. The veteran should be told that the information is necessary to obtain supportive evidence of the stressful events and that failure to respond may result in adverse action. 3. With the information supplied by the veteran in (2) in hand, and based upon a review of the information already contained in the claims file, the RO then prepare a request to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, for verification of the incident or incidents which the veteran alleges are "stressors." Any information obtained is to be associated with the claims folder. With respect to the alleged death of Sergeant King, or any other individual the veteran alleges was killed in his unit, if the veteran provides information on the date and circumstances of such a death, the RO should contact the Director, National Archives and Records Administration, (NARA), ATTN: NCPNA-O 9700 Page Boulevard, St. Louis, Missouri 63132, and request copies of the morning reports or equivalent records for the 6256th Support Squadron at Cam Ranh Bay, in October 1965, the 6256th Forward Service Squadron, from November 1965 to December 1965 or the 12th Service Squadron, from December 1965 to October 1966 to verify such information. 4. Following the actions in (3), the RO must review the record and enter a specific determination as to whether an event or events alleged as a "stressor" is verified in accordance with the discussion above of the governing regulations and Zarycki. In this regard, the RO must specifically rule on whether it finds that the veteran "engaged in combat with the enemy." If the RO determines that no event alleged as a stressor is verified and established, the claim for service connection for PTSD should be denied on that basis without any further action. If the RO determines that an event or events alleged as "stressors" is confirmed, then the RO should enter a specific finding as to the nature of such an event or events. 5. If, and only if, the RO determines that an event or events alleged as a "stressor" is established, the RO should then arrange to afford the veteran an examination by a panel of two VA board-certified psychiatrists, if available, who have not previously examined him to determine whether the appellant suffers from any psychiatric disorder and if so, its nature and etiology and severity. The RO must specify to the examiners the event or events alleged as "stressors" in service which have been confirmed. The examination report should include a detailed account of all pathology found to be present. If there are psychiatric disorders other than PTSD, the examiners should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be dissociated from one disorder or another, it should be specified. If a diagnosis of PTSD is appropriate, the examiners should specify whether it is proximately due to an event or events in service confirmed by the RO. The examiners should further specify whether any of the event or events in service confirmed by the RO is of the quality required to constitute a "stressor" for purposes of establishing the presence of PTSD. The examiners should also describe which stressor(s) the veteran reexperiences and how he reexperiences them. The psychiatrists should describe how the symptoms of any psychiatric disorder shown to be present affect the appellant's social and industrial capacity. The report of the examination should include a complete rationale for all opinions expressed. All necessary special studies or tests. The examiners should assign a numerical score based on the Global Assessment of Functioning Scale (GAF) provided in DSM-III-R. It is imperative that the physicians include a definition of the numerical code assigned under DSM-III-R in order to permit the RO and the Board to comply with the requirements of Thurber v. Brown, 5 Vet.App. 119 (1993). The claims folder and a copy of this Remand should be made available to the examiners for review in conjunction with the examinations. 6. The RO should then review the record and assure that all of the above actions are completed. If a diagnosis of PTSD is of record, the RO must also make a determination as to whether the existence of an adequate stressor or stressors has been established consistent with Zarycki and West. When the foregoing development has been completed, the claim should be reviewed by the RO. If the decision remains adverse to the veteran, a supplemental statement of the case should be prepared and the veteran should be given a reasonable period of time for reply. Thereafter, the claim should be returned to the Board for further review, if in order. No action is required of the veteran until he receives further notice. The purpose of this REMAND is to obtain additional information. The Board does not intimate any factual or legal conclusions as to the ultimate outcome warranted in this appeal. RICHARD B. FRANK 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).