BVA9502572 DOCKET NO. 89-28 248 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Wichita, Kansas THE ISSUE Entitlement to an increased rating for anxiety neurosis with post-traumatic stress disorder, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Christine E. Puffer, Associate Counsel INTRODUCTION The veteran had active service June 1941 to April 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1994 rating decision of the Department of Veterans Affairs (VA) Wichita, Kansas, Regional Office (RO) which confirmed and continued the denial of the benefit sought on appeal. REMAND An April 1994 social and industrial survey report noted that the veteran's post-traumatic stress disorder symptoms appeared to have worsened, with increased severity. It was stated that the veteran exhibited "obvious" social and industrial impairment, and a guarded prognosis was offered. A July 1994 post-traumatic stress disorder clinic entry indicated that the veteran continued to have nightmares two to three times a week, intrusive thoughts triggered by July 4th festivities, increased startle response, poor appetite, slight improvement in his mood, although no improvement in his irritability. At an August 1994 hearing, the veteran testified that he hardly interacted socially, was rather socially isolated, and had problems being around small children and crowds. He reported experiencing vivid nightmares several times a week, which often woke him up. The veteran indicated that when he became nervous he became confused and unable to think. In a November 1994 statement, the veteran's representative cited two VA medical record entries of August and September 1994 which purportedly described the veteran's level of disability attributable to his post-traumatic stress disorder to be chronic and severe, rendering him unemployable. The representative has cited these findings in contending that the veteran's post- traumatic stress disorder should be rated as 70 percent disabling. The most recent entries of record evidence treatment of the veteran prior to those dates. The duty to assist includes the obtaining of all relevant medical records. Dyess v. Derwinski, 1 Vet.App. 90, 92 (1991). Additionally, the Board is required to extend a liberal reading to include issues raised in all documents submitted prior to a decision. See Douglas v. Derwinski, 2 Vet.App. 435 (1992). In light of this duty, the Board finds that the veteran has raised the issue of entitlement to a total rating based on individual unemployability due to service-connected disability. See E.F. v. Derwinski, 1 Vet.App. 118, 121 (1991). The medical director of a VA post-traumatic stress disorder clinic conducted a biopsychosocial evaluation of the veteran. The assessment included a diagnosis of major depression secondary to post-traumatic stress disorder. A post-traumatic stress disorder clinic entry of July 1994 noted, in part, an impression of major depressive disorder secondary to post-traumatic stress disorder. The veteran's representative contended in a January 1995 written argument that the VA had improperly evaluated the veteran's depression. It was indicated that secondary service connection should be considered for the veteran's diagnosed major depression. As the veteran has reasonably raised the issue of entitlement to service connection for major depression secondary to post-traumatic stress disorder, this issue is referred to the RO for appropriate development. As the Board finds that additional development of the evidence is necessary, this case is REMANDED for the following action: 1. The RO should obtain all treatment records of the veteran from the Wichita VA Medical Center, including both outpatient and hospitalization reports, inclusive from August 1994 to the present. 2. If, after review of the above records, the RO determines that there is a question as to the severity of the veteran's post- traumatic stress disorder, the veteran should be afforded a psychiatric examination to determine the nature and extent of any psychiatric disorder(s) that may be present, to include post-traumatic stress disorder. All tests deemed necessary by the examiner should be performed. The examiner is specifically requested to offer an opinion as to the degree of impairment attributable individually to each psychiatric disorder, if any. The examination should include an analysis of the veteran's level of functioning as measured by the Global Assessment of Functioning Scale (GAF Scale) as stated in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised 1987) (DSM-III-R), and the degree of impairment of the veteran to perform substantially gainful employment. The claims folder is to be made available to the examiner for review prior to, and during, the examination. The rationale for all opinions expressed should be stated. 3. When the development requested in the above paragraphs has been completed, the case should again be reviewed on the basis of the additional evidence. In addition to the issue certified on appeal, the RO should also adjudicate the issues of entitlement to service connection for major depression as secondary to post-traumatic stress disorder, and entitlement to a total rating based on individual unemployability due to service-connected disability. If any of the determinations are adverse to the veteran, he and his representative should be notified of the decisions, and of the veteran's procedural and appellate rights. If a timely notice of disagreement is received, the normal appellate procedures should be followed. Following completion of the above actions, the case should be returned to the Board for consideration of all issues in appellate status. The purpose of this REMAND is to assist the veteran in the development of his claim, and the Board does not intimate any opinion as to the merits of this case, either favorable or unfavorable, at this time. No action is required of the veteran until he is notified. WARREN W. RICE, JR. 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).