BVA9503918 DOCKET NO. 93-00 970 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for a chronic acquired psychiatric disorder, variously diagnosed, including post- traumatic stress disorder. 2. Entitlement to a permanent and total disability rating for pension purposes. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from May 1970 to December 1973. This appeal arose from March and October 1991 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The RO respectively denied entitlement to a permanent and total disability rating for pension purposes and to service connection for a chronic acquired psychiatric disorder, variously diagnosed, including post-traumatic stress disorder. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. REMAND The appellant is a veteran of the Vietnam era having been trained as a cook. It is neither contended nor is it shown that he served in Vietnam or had any combat service. The stressor reported by the appellant to account for his having been diagnosed with post-traumatic stress disorder is an incident whereby another serviceman shot up his barracks. The medical evidence of record discloses varying psychiatric diagnoses, including post-traumatic stress disorder as noted above, to account for his symptomatology. A review of the record discloses the veteran has not been accorded an examination by a board of VA psychiatrists in order to reconcile the varying psychiatric diagnoses. It does not appear that any development was undertaken by the RO to verify the claimant's alleged stressor. There is no service department verification of such an event. Under 38 C.F.R. § 3.304(f) (1993), service connection for post- traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence establishing that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. In addition, VA's Manual M21-1 contains specific procedures to follow in evaluating claims for service connection for post- traumatic stress disorder. Manual M21-1, Part VI, Para 7.46(e), (f) (Dec. 21, 1992). As to the issue of entitlement to a permanent and total disability rating for pension purposes, the Board observes that prior to the transfer of the appellant's case to the Board for appellate review, the RO was attempting to secure the medical records utilized by the Social Security Administration which led to an award of Social Security Disability benefits. Correspondence had been sent to the veteran seeking his help in obtaining such records; however, an incorrect address was utilized in the attempt to contact him and he never received such correspondence from the RO, nor did he receive supplemental statements of the case issued by the RO. Furthermore, the veteran has not been afforded a comprehensive examination to determine the nature and extent of severity of any and all disorders which may be present. His correct address has since been associated with the claims file. Therefore, pursuant to VA's duty to assist the appellant in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.103(a), the Board is deferring adjudication of the issues certified for appellate review pending a REMAND of the case to the RO for further development as follows: 1. The RO should obtain from the Social Security Administration the records pertinent to the appellant's claim for Social Security benefits as well as the records relied upon concerning that claim. If records pertaining to such claim and medical evidence utilized in processing such claim are not available, that fact should be entered in the claims file. 2. The RO should contact the veteran and request that he provide the names and addresses of any health care providers, other than VA who have treated him for a psychiatric disability, including post- traumatic stress disorder and specify the approximate dates of treatment, if possible. Then, after any necessary authorization is obtained from the veteran, the RO is to obtain copies of all treatment records for the veteran from the health care providers identified which have not been previously secured. 3. The RO should request from the veteran a statement containing as much detail as possible regarding the alleged stressful event to which he was exposed in service. He should be asked to provide the specific details of the claimed stressful event during service, such as the date, place, detailed description of the event, his service unit, duty assignment and the name(s), rank(s), unit of assignment and any other identifying information concerning any other individuals involved in the events. The claimant should be told that the information is necessary to obtain supportive evidence of the stressful event and that failure to respond may result in adverse action. 4. The RO should contact the Director, National Archives and Records Administration, (NARA), ATTN: NCPNA-O 9700 Page Boulevard, St. Louis, Missouri 63132, and request appropriate information in accordance with statement submitted by the veteran. The stressor information obtained from the veteran should be forwarded to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, for verification of the incident which the veteran reports he reexperiences. Any information obtained is to be associated with the claims folder. 5. The RO should arrange for a comprehensive general medical examination. This study is to determine the nature and severity of all of the appellant's disorders. All indicated studies are to be conducted. The examiner(s) conducting the examination(s) are requested to provide an opinion as to the impact of the veteran's disabilities (excluding polydrug abuse) on his ability to secure or follow a substantially gainful occupation. All opinions expressed must be accompanied by a complete rationale. 6. The veteran should then be afforded an examination by a panel of VA psychiatrists to determine whether the appellant suffers from any psychiatric disorder and if so, its nature, etiology, and severity. The examination report should include a detailed account of all pathology found to be present. If there are psychiatric disorders other than post-traumatic stress disorder, the examiners should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be dissociated from one disorder or another, it should be specified. If a diagnosis of post-traumatic stress disorder is appropriate, the examiners should specify the credible "stressor(s)" that caused the disorder and the evidence upon which they relied to establish the existence of the stressor(s). The examiners should also describe which stressor(s) the veteran reexperiences and how he reexperiences them. The psychiatrists should describe how the symptoms of any psychiatric disorder shown to be present affect the appellant's social and industrial capacity. The report of examination should include a complete rationale for all opinions expressed. All necessary studies or tests, including psychological testing are to be accomplished. The examiners should assign a numerical score based on the Global Assessment of Functioning Scale (GAF) provided in DSM-III-R. It is imperative that the psychiatrists include a definition of the numerical code assigned under DSM- III-R in order to comply with the requirements of Thurber v. Brown, 5 Vet.App. 119 (1993). The entire claims file and a copy of this remand must be made available to and reviewed by the examiners prior to the examinations. 7. Thereafter the RO should review all examination reports to ensure that they are in complete compliance with the instructions contained in the remand. If the examination reports are not in complete compliance, appropriate corrective action is to be implemented at once. 8. Then , the RO should evaluate the veteran's disabilities, assigning a rating for each. 9. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for a chronic acquired psychiatric disorder, variously diagnosed, including post-traumatic stress disorder, and a permanent and total disability rating for pension purposes consistent with the criteria under 38 U.S.C.A. §§ 1502(a)(1), 1521(a); 38 C.F.R. §§ 3.321(b)(2), 4.15, 4.16, 41.7, 4.25. If the benefits requested on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case including the provisions of the appropriate diagnostic codes under which the RO rated each of the appellant's disorders, as well as a discussion of the average person standard and unemployability standard by which a permanent and total disability rating for pension may be assigned. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for further appellate review, in otherwise in order. By this REMAND, The Board intimates no opinion to any final outcome warranted. No action is required of the veteran until he is notified by the RO. ALBERT D. TUTERA 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).