Citation Nr: 0003300 Decision Date: 02/09/00 Archive Date: 02/15/00 DOCKET NO. 98-13 621 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Kelli A. Kordich, Associate Counsel INTRODUCTION The veteran served on active duty from February 1969 to August 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, that continued a 30 percent evaluation for the veteran's post-traumatic stress disorder. REMAND Initially, the Board finds that the claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, he is found to have presented a claim that is plausible. See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Board denied the veteran's claim for an evaluation in excess of 30 percent for post-traumatic stress disorder in a decision dated in April 1996. His reopened claims for increased ratings for this disability were continued on two occasions thereafter. In a reopened claim received in May 1997, the veteran again requested an increased evaluation for his service-connected post-traumatic stress disorder. Rating decisions dated in September 1997 and March 1998 denied his claim. His notice of disagreement with these determinations was received in May 1998. Thus, the veteran has continuously prosecuted his claim for increase since its receipt in May 1997. The Board notes that the veteran's most recent VA examination was conducted in May 1996. Subsequent to the May 1996 examination, the veteran has had numerous VA hospitalizations and outpatient treatment concerning his post-traumatic stress disorder. In November 1998, the veteran was placed on an off-duty status at his job with the Postal Service in response to the veteran indicating that he had been diagnosed with post-traumatic stress disorder, which caused him to be homicidal and suicidal at work. The Board further notes that there has been conflicting medical information from VA psychiatrists as to the veteran's condition. A note of October 1998 shows that the veteran reported saying that he would like to be admitted right then or he would hurt someone and stated that his post-traumatic stress disorder was acting up and that Vietnam was coming out of him. The veteran was advised that there were no beds at that time. The psychiatrist indicated that since the veteran showed more self-control than he was claiming, the psychiatrist encouraged him to think through what steps to take. The veteran got up and tore papers off the psychiatrist's desk and walls and scattered them on the floor. The psychiatrist indicated that the veteran was infantile and manipulative with his threats and intimidating tactics. A VA social worker also indicated that he has observed the veteran behaving in the same manner. The psychiatrist indicated that the veteran had many interpersonal problems, particularly with his wife. A VA physician who recently submitted two statements dated in May 1999 and January 2000 indicated that he was the Director of the PTSD program and a Major in the United States Army Reserves. This physician indicated in his May 1999 statement that the PCT staff strongly felt that the veteran was dysfunctional due to his chronic PTSD. His January 2000 statement indicated that the veteran had recently been hospitalized and that his symptoms seriously interfered with his personal life and work. This recent hospitalization report is not of record. The Board is of the opinion that a comprehensive psychiatric compensation examination that also addresses all of the evidence of record in recent years would be helpful to an equitable disposition of this appeal. Accordingly, the case is REMANDED to the RO for the following: 1. The RO should request that the veteran provide the names and addresses of all health care providers who have treated him for any psychiatric disorder. After obtaining any necessary authorization from the veteran, the RO should obtain and associate with the claims folder legible copies of the veteran's complete treatment records from those facilities identified by the veteran which have not already been secured. Regardless of the veteran's response, the RO should obtain all outstanding VA records of treatment, specifically any outstanding hospitalization reports. 2. If the veteran is in receipt of Social Security disability benefits, the RO should, if possible, obtain Social Security Administration records pertaining to the finding of disability; the RO should also obtain copies of any available employment records from the veteran's most recent employer, the United States Postal Service, if possible. These records should be associated with the claims folder. 3. The RO should schedule the veteran for a psychiatric examination in order to assess the current severity of his service-connected PTSD. The examination should be conducted by a physician who has not previously examined the veteran. The claims folder and a copy of this REMAND should be made available to the examiner, and the examiner is requested to review the record in this case in conjunction with the examination of the veteran. The examiner is requested to note in the examination report whether the claims folder was received and reviewed. All indicated tests should be undertaken, and all manifestations of current disability should be described in detail. If more than one disorder is diagnosed, the examiner is requested to distinguish, if possible, the symptomatology attributable to the service-connected PTSD from symptomatology attributable to nonservice-connected psychiatric disorders. The examiner is requested to provide an opinion as to the veteran's current functioning and identify the conditions that limit his employment opportunities. Following the examination, the examiner should provide a numerical score on the Global Assessment of Functioning (GAF) Scale, as described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The examiner is requested to include a definition of the numerical GAF score assigned, as it relates to the veteran's occupational and social impairment. 4. Thereafter, the RO should review the claims folder to ensure that the requested development has been completed to the extent possible. Then, the RO should readjudicate the issue of entitlement to an increased evaluation for PTSD. If the determination remains adverse to the veteran, the veteran and his representative should be furnished a supplemental statement of the case and given an appropriate time in which to respond. The record should then be returned to the Board for further appellate review, if otherwise in order. The purpose of this remand is to ensure a complete record for appellate review and to assist the veteran with the development of evidence in connection with his claim. The Board intimates no opinion, either legal or factual, as to the ultimate disposition of this appeal. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). WILLIAM W. BERG Acting Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 1999), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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).