Citation Nr: 0001291 Decision Date: 01/14/00 Archive Date: 01/27/00 DOCKET NO. 98-12 938 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to an evaluation in excess of 30 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The veteran served on active duty from January 1970 until November 1970. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) from a rating decision of June 1998 from the Louisville, Kentucky Regional Office (RO) which granted service connection for PTSD, rated 10 percent disabling. By rating action of December 1998, the 10 percent disability evaluation for PTSD was increased to 30 percent from the date of the claim received in October 1997. The veteran continues to express dissatisfaction with the current rating determination. REMAND The veteran contends that the symptoms associated with his service-connected PTSD are far more disabling than represented by the 30 percent disability evaluation currently in effect, and warrant a higher rating. A review of the claims folder reflects that the appellant obtained regular and continuing outpatient follow-up and medication management for his psychiatric symptoms in the VA mental hygiene clinic dating from 1994. It is shown that he complained of significant problems which included chronic depression, sleep difficulties, a sense of worthlessness, hopelessness, inability to handle his anger, irritability, nightmares, intrusive thoughts, memory lapses and lack of concentration, as well as isolationist behavior. He was hospitalized at a VA facility in June 1998 for chronic psychiatric symptoms, including suicidal thoughts. Pertinent diagnoses upon discharge included depression, not otherwise specified, and history of PTSD. However, these assessments are contrasted with the more longitudinal VA outpatient treatment notes dating from 1994 revealing a consistent diagnosis of major depression, although rule out PTSD and rule out a personality disorder were recorded on one occasion. As noted previously, no VA outpatient records have been associated with the claims folder since July 1998. The Board is of the opinion that current records in this regard would be useful. Additionally, the record reflects that the veteran was most recently afforded a VA psychiatric examination for compensation and pension purposes in January 1998. It is observed in the rating determinations of June 1998 and December 1998 that the appellant would be scheduled for a future VA examination in January 2000 to assess the current degree and severity of his service-related psychiatric disorder. Since that time is close at hand as of this writing, and in view of the foregoing, the Board finds that the veteran should be accorded a VA psychiatric examination for the purpose of determining the current severity of his service-connected PTSD. The Board is also of the opinion that a current and more thorough examination would be helpful in reconciling the varying diagnoses which have been rendered in this case. The Court of Veterans Appeals has held that the VA has a duty to assist the veteran in the development of facts pertinent to his claim, to include securing medical records to which reference has been made, and a thorough and complete medical examination so that the evaluation of the claimed disability will be a fully informed one." See Hyder v. Derwinski, 1 Vet.App. 221 (1991); Green v. Derwinski, 1 Vet.App. 121, 124 (1991); Gilbert v. Derwinski, 1 Vet.App. 49,55 (1990). The RO should also be requested to consider whether different ratings may be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, No. 96-947 (U.S. Vet. App. Jan. 20, 1999). Accordingly, the case is therefore REMANDED to the RO for the following actions: 1. Any and all VA outpatient and/or inpatient records dating from August 1998 should be requested and associated with the claims folder. 2. The RO should schedule the veteran for a VA psychiatric examination, in order to determine the extent of the service-connected PTSD. All necessary tests and studies, including appropriate psychological studies (if determined to be necessary by the psychiatrist), should be conducted in order to identify and describe the symptomatology attributable to PTSD. The report of examination should contain a detailed account of all manifestations of the disability(ies) found to be present. If there are found to be psychiatric disorder(s) other than PTSD, the examiner should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be disassociated from one disorder or the other, it should be so specified. The examiner must also comment on the extent to which PTSD affects occupational and social functioning. A multi-axial assessment should be conducted, and a thorough discussion of Axis IV (psychosocial and environmental problems) and Axis V (Global Assessment of Functioning (GAF) score), with an explanation of the numeric code assigned, is to be included. The claims folder and a copy of this remand must be made available to the psychiatrist for review in conjunction with the examination. It should be indicated by the examiner whether the claims folder has been reviewed. The complete rationale for any opinion expressed must be set forth in a legible report. 3. Prior to the examination, the RO must inform the veteran, in writing, of all consequences of his failure to report for the examination in order that he may make an informed decision regarding his participation. 4. The RO should review the examination report to determine if it is in compliance with this REMAND. If deficient in any manner, it should be returned, along with the claims file, for immediate corrective action. 5. After completing any necessary development in addition to that specified above, the RO should readjudicate the claim of entitlement to a disability rating greater than 30 percent for PTSD, with application of the tenets of Fenderson, to determine whether "staged" ratings are warranted for manifestations of the service- connected disability. If the disposition remains unfavorable to the veteran, the RO should furnish him and his representative with a supplemental statement of the case and afford him the opportunity to respond. Thereafter, the case should be returned to the Board for final appellate review, if in order. The purpose of this REMAND is to ensure compliance with VA's duty to assist and to afford the veteran due process of law. The Board intimates no opinion as to the ultimate outcome of the veteran's claim. No action is required of the veteran until further notice. U. R. POWELL Member, Board of Veterans' Appeals 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) (1999).