BVA9504951 DOCKET NO. 93-13 441 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for a chronic acquired psychiatric disability, to include post-traumatic stress disorder. REPRESENTATION Appellant represented by: Georgia Department of Veterans Service ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION In December 1991, the veteran was informed that immediate action on his claim for benefits based on Agent Orange exposure was being deferred until new regulations became effective. The regulations have since been revised, and diseases associated with exposure to certain herbicide agents are enumerated in 38 C.F.R. § 3.309(e) (1994). Therefore, claims for service connection for disabilities based on exposure to Agent Orange may now be adjudicated. See VBA Circular 21-94-1 (Feb. 15, 1994). This matter is referred to the RO for appropriate consideration. REMAND The veteran had active service from June 1968 to June 1972. He served in Vietnam from December 1968 to November 1969. His medals and badges included the Combat Action Ribbon. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. During hospitalization by VA from November to December 1991, the veteran's complaints included frequent nightmares about his experiences in Vietnam. Elaboration was not provided. The final Axis I diagnoses were major depressive disorder and a history of substance abuse. He was seen in VA outpatient consultation later in December 1991 for followup of his major depression. Notation was again made of nightmares and flashbacks. Again, elaboration was not provided. The Axis I diagnoses were: Major depression; alcohol dependence; and rule out post-traumatic stress disorder. The veteran was accorded a special psychiatric examination by VA in July 1992. Reference was made to the VA hospitalization in late 1991. It was stated that although the veteran mentioned some symptoms such as feeling sad, having frequent nightmares about Vietnam and having a decreased appetite, these apparently were not considered sufficient to warrant the diagnosis of post- traumatic stress disorder. Reference was also made to psychological testing done during the hospitalization which indicated that the results of the evaluation might not be valid. The veteran reportedly was uncooperative and hostile during most of the testing. The tests reportedly did not substantiate the diagnosis of post-traumatic stress disorder. Records pertaining to the testing are not in the claims file. The Axis I diagnosis was dysthymia, secondary to legal and financial problems. Notation was made of a history of substance abuse. The Axis II diagnosis was a mixed personality disorder manifested by sociopathic tendencies. In a December 1992 communication, the veteran described generally his experiences in Vietnam and their impact on his life following service. Although the above-mentioned evidence does not indicate the veteran has been accorded a diagnosis of post-traumatic stress disorder, notation was made that it was to be ruled out following the outpatient visit in late December 1991. Further, the examiner, during the July 1992 psychiatric examination, seemed to rely on psychological testing, the results of which are not in the claims folder, as not substantiating the diagnosis of post- traumatic stress disorder. However, notation was made that the veteran was uncooperative and hostile during most of the testing. In light of the foregoing, and recognizing its duty to assist the veteran in the development of facts pertinent to his claim, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that he provide the names and addresses of all health care providers who have treated him for post-traumatic stress disorder and specify the approximate dates of treatment, if possible. Then, after any necessary authorization is obtained from the veteran, the RO should obtain copies of all treatment records for the veteran from the health care providers identified. In any event, copies of VA medical records pertaining to psychiatric treatment of the veteran since 1991 should be obtained and associated with the claims folder. Of particular interest are the reports of psychological testing accorded the veteran, apparently during hospitalization at the VA Medical Center, Downtown Division, Augusta, Georgia 30910. 2. Thereafter, the RO should arrange for the veteran to be accorded a VA psychiatric examination by a physician who has not previously examined him to determine the diagnoses of all psychiatric disorders that are present. The examination report should reflect review of pertinent material in the claims folder. The examiner should integrate the previous psychiatric findings and diagnoses with the current findings to provide a comprehensive picture of the nature of the veteran's psychiatric status. If the diagnosis of post-traumatic stress disorder is deemed appropriate, the examiner should comment upon the link between the current symptomatology and one or more of the inservice stressors found to be sufficient to produce post-traumatic stress disorder. The report of examination should include the complete rationale for all opinions expressed. All necessary special studies or tests, to include psychological testing and evaluation, such as the Minnesota Multiphasic Personnel Inventory and the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorders, should be accomplished. The claims folder and a copy of this REMAND must be made available to the examiner prior to the examination. 3. The RO should then review the record and ensure that all the above actions have been completed. When the RO is satisfied that the record is complete and the psychiatric examination is adequate for compensation purposes, the claim should be readjudicated. Unless the benefit sought on appeal is not granted, a supplemental statement of the case should be prepared and the veteran and and his representative should be provided with the applicable time period in which to respond. Thereafter, the claim should be returned to the Board for further review, if otherwise in order. No action is required of the veteran until he receives further notice. The Board does not intimate any factual or legal conclusions as to any final outcome warranted in the appeal. CHARLES E. HOGEBOOM 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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) (1994).