BVA9507410 DOCKET NO. 93-14 459 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for alcohol and drug abuse. 2. Entitlement to an increased rating for post-traumatic stress disorder, currently rated 30 percent disabling. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Mark J. Swiatek, Counsel INTRODUCTION The veteran had active military service from February 1970 to October 1971. This appeal comes before the Board of Veterans' Appeals (Board) from an April 1992 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico, that denied service connection for alcohol/drug abuse, granted service connection for post-traumatic stress disorder (PTSD) and rated the disorder 30 percent disabling. The veteran also receives a 10 percent rating for tinnitus. He has several other service- connected disabilities currently rated noncompensable. The attention of the RO is directed to the representative's June 2, 1992, communication to the RO seeking consideration for service connection broken ribs. And, to a January 7, 1994, written argument to the Board wherein the issue of service connection for residuals of a head injury is raised. The issues have not been adjudicated in connection with the current claim. They are referred to the RO for further action. REMAND It is asserted by the appellant, in essence, that the substance abuse is related to his post-traumatic stress disorder (PTSD), and that the PTSD symptoms are more disabling than reflected in the current rating. The record reflects that the April 1992 rating decision granting service connection for post-traumatic stress disorder held that the veteran's alcohol and drug dependence was the result of willful misconduct. A review of the record discloses that the decision was made without benefit of a complete record or a medical opinion regarding the claimed relationship between the veteran's PTSD and the substance abuse. The Board observes that the record of VA hospitalizations in 1989 and 1991 and the report of a March 1992 psychiatric examination reflect that the veteran apparently had received pertinent medical treatment for which no records are currently included in the claims folder. The Board also notes that in July 1992 the veteran completed an application for vocational rehabilitation services. However, no records from the vocational rehabilitation service have been associated with the claims folder. After a review of the record, in particular the representative's May 1993 written argument to the Board, the Board finds that the appeal may reasonably be interpreted as including a claim for a total compensation rating based on individual unemployability on account of a service-connected psychiatric disability. As previously noted, the veteran's psychiatric disability is not currently his only compensable rated service-connected disability. To ensure that the VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should obtain and associate with the claims folder any records of vocational counseling or rehabilitation accorded the veteran. If no records are available, documentation of this fact should be added to the records assembled for appellate review. 2. The veteran should be provided with an application for increased compensation based on individual unemployability due to service- connected disability. He should also be requested to identify all sources of recent treatment for his service-connected psychiatric disability, and the sources of treatment for alcohol/substance abuse at any time since service. With any necessary authorization from the veteran, the RO should attempt to obtain copies of all indicated records which have not been previously secured. 3. A VA social and industrial survey should be conducted in order to clarify the veteran's medical, social, educational, and employment history. The social worker should elicit and set forth pertinent facts regarding the veteran's medical history, education, employment history, social adjustment, and current behavior and health. The social worker should offer an assessment of the veteran's current functioning and identify the conditions which limit his employment oppor- tunities. Any potential employment opportunities should be identified. The claims folder must be made available to the social worker in conjunction with the survey as it contains important historical data. 4 Following completion of the above development, the veteran should be accorded a VA psychiatric examination to determine the severity of the PTSD. The claims folder must be made available to the examiner prior to the evaluation so that the examiner may review the pertinent historical data contained therein. The examiner should utilize the social work service report as well as pertinent data in the claims folder in order to obtain a true picture of the extent of the veteran's psychiatric disability. The examination should be comprehensive enough to determine the nature and extent of all psychiatric symptoms. Any relationship between the PTSD and any other psychiatric disorder found should be identified. The psychiatrist should utilize any psychological testing deemed pertinent in making a complete diagnostic evaluation and in differentiating the PTSD symptoms from those attributable to other conditions. Based upon a review of the record and the examination, the physician should provide a Global Assessment of Functioning (GAF) scale code and discuss the meaning of the GAF scale code assigned. The psychiatrist should be requested to review the claims folder and provide an opinion regarding the etiology of any alcohol/substance abuse disorder found and its relationship to PTSD. In addition, the examiner should also discuss the impairment of the veteran's ability to establish and maintain relationships as well as the reduction in initiative, efficiency and reliability levels which may be attributable to the PTSD (as distinct from impairment attributable to other conditions). 5. When the above development has been completed the RO should readjudicate the veteran's claim. If it has not been rendered moot, the claim for a total rating based on individual unemployability on account of service-connected disability should also be adjudicated. The rating should reflect consideration of the applicability of the provisions of 38 C.F.R. §§ 3.321(b)(1) and 4.16(b) or 4.16(c), whichever may be applicable. If any benefit sought on appeal is not granted to the veteran's satisfaction, a supplemental statement of the case addressing all issues in appellate status should be prepared and furnished to the veteran and his representative. They should be provided the applicable period in which to respond. Thereafter, in accordance with the proper appellate procedures, the case should be returned to the Board for further appellate review, if otherwise in order. In taking this action, the Board implies no conclusion, either legal or factual, as to any final outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. 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 deter- mination. 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 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).