BVA9505088 DOCKET NO. 93-15 966 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida 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 August 1965 to February 1970. This appeal arises from a November 1992 rating decision of the St. Petersburg, Florida, Regional Office (RO). In a December 1993 statement, the issue of entitlement to a total rating based on individual unemployability due to service connected disability was raised; however, that issue has not yet been developed for appellate review and 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). With respect to the September 1992 VA psychiatric examination report, the Board notes that the examiner did not have the veteran's medical records available for review, and the report did not provide a Global Assessment of Functioning scale code or otherwise indicate the degree to which the psychiatric disorder results in reduction in initiative, flexibility, efficiency and reliability levels. In a deferred rating decision dated in February 1993, a rating specialist noted that the veteran claimed that he was captured, tortured, and held a prisoner of war (POW) and that a private psychologist, Edward W. Chandler, Ph.D., listed these experiences as a major stressor resulting in PTSD symptoms. The rating specialists also noted that the National Personnel Records Center (NPRC) had failed to verify the veteran's former POW status and that additional information was needed from the veteran in order to attempt to verify the claimed stressors. A statement of the case dated in March 1993 suggested to the veteran that he might wish to assist in verification of his claimed former POW status by providing additional details, and that action would be deferred pending his response. The veteran did not reply. The reply from the NPRC which reflects that no POW status was indicated by official records at that facility, as well as the veteran's failure to provide details needed for additional research, reflects badly upon the credibility of the veteran with regard not only to this claimed stressor, but also as to the reported PTSD symptoms. As noted in the Physician's Guide for Disability Evaluation Examinations, "the clinical picture of post-traumatic stress disorder is relatively easy to fabricate on a superficial level but very difficult to fabricate in depth. Thus, the more detailed the history taking, the greater the validity." A psychiatric examination will be helpful in eliciting such details and in clarifying the nature and severity of symptoms which can be linked to inservice traumatic events. 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). The veteran has been receiving ongoing treatment at Psychiatric Associates. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should request the veteran to identify 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 Psychiatric Associates since December 1992. Once obtained, all records must be associated with the claims folder. 2. The RO should request from the veteran a comprehensive statement containing as much detail as possible regarding his claimed POW experiences. The veteran should be asked to provide specific details, such as dates, places, detailed descriptions of events, and identifying information concerning any other individuals involved in the events. The veteran is advised that this information is vitally necessary to obtain supportive evidence of the stressful event and that he must be as specific as possible because without such details an adequate search for verifying information cannot be conducted. 3. If additional information is obtained, the RO should send the pertinent documents to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150. They should be requested to provide any information which might corroborate the veteran's alleged POW experience. 4. Following the above, the RO must make a specific determination, based upon the complete record, with respect to whether the appellant was a former POW. In reaching this determination, the RO should address any credibility questions raised by the record. 5. The RO should arrange for the veteran to be scheduled for a comprehensive VA psychiatric examination. The examination should be conducted in accordance with the VA Physician's Guide for Disability Evalu- ation Examinations. All indicated tests, including appropriate psychological studies, should be conducted. The claims file must be made available to and reviewed by the examiner prior to the examination. After reviewing pertinent documents in the claims folder, including the 1990 and 1992 VA psychiatric examination reports and the July and December 1992 reports from Dr. Chandler, the examiner should elicit and record the veteran's account of inservice stressful events and current psychiatric symptoms in as much detail as possible. A specific statement should be made as to the apparent reliability of the veteran with regard to history and symptoms. The examiner should specify which stressors were accepted as credible and explain how the stressors are related to current psychiatric symptoms. The examiner should assign a Global Assessment of Functioning Scale code, 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 the PTSD (as distinct from impairment attributable to other conditions). 6. When the requested development is fully completed, the RO should readjudicate the veteran's claim. The rating decision should reflect consideration of the ap- plicability of the provisions of 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.129, and 4.130. If the claim is not 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. GARY L. GICK 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 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) (1993).