BVA9505537 DOCKET NO. 93-13 705 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an increased rating for post traumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel INTRODUCTION The veteran had active service from January 1967 to December 1968. This appeal arises from a May 1991 rating decision of the St. Petersburg, Florida, Regional Office (RO). Since that time, the veteran has relocated to Tennessee and his claim is currently being handled by the Nashville RO. The Board notes that the veteran has raised the issue of entitlement to a total disability rating based on individual unemployability due to service connected disability; however, that issue has not been developed on appeal and it is referred to the RO for appropriate consideration. REMAND The duty to assist includes conducting a thorough and contemporaneous examination of the veteran that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). This is to ensure that the evaluation of a disability is a fully informed one. The severity of psychiatric disability is based upon actual symptomatology as it affects social and industrial adaptability. See 38 C.F.R. §§ 4.129, 4.130 (1993). Since the last Department of Veterans Affairs (VA) psychiatric examination in March 1991, the veteran has been hospitalized on several occasions to include a period from January to February 1993 when he was admitted with complaints of sleep impairment, increased anxiety, flashbacks, and suicidal ideation. Upon discharge, the veteran was scheduled for follow-up with the mental health clinic. In view of the foregoing, the Board is persuaded that the veteran should be afforded a further VA psychiatric examination in connection with this appeal. VA has a duty to assist the veteran in the development of facts pertaining to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals (Court) has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal. The duty to assist is neither optional nor discretionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). Complete current records should be obtained to include those from the Mountain Home VA medical center. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and obtain the names and addresses of all mental health care providers from whom he has received treatment in recent years. Thereafter, the RO should obtain legible copies of all records which have not already been obtained to include those from the mental health clinic at the Mountain Home VA medical center since February 1993. Once obtained, all records must be associated with the claims folder. 2. Following completion of the above development, the veteran should be afforded a comprehensive VA examination in psychiatry. This study should be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, should be conducted. The claims file must be made available to and reviewed by the examiner prior to the examination. The disability should be evaluated in relation to its history, with emphasis upon the limitation of activity, to include time lost from employment, imposed by the service-connected psychoneurosis. The examiner should assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual For Mental Disorders, and explain what the assigned score represents. 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 PTSD (as distinct from impairment attributable to other conditions). 3. Following completion of the foregoing, the RO must review the claims folder and ensure that the foregoing development has been completed in full. If any development is incomplete, appropriate corrective action should be implemented. When the requested development is fully completed, the RO should readjudicate the veteran's claim. The rating decision should reflect consideration of the applicability of the provisions of 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.129, and 4.130. Unless the claim is granted to the veteran's satisfaction, he and his representative should be furnished with a supplemental statement of the case. They should then be afforded the applicable time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. 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).