BVA9505158 DOCKET NO. 93-14 449 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel REMAND The veteran had active service from October 1967 to October 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California, which confirmed and continued a 30 percent schedular rating for the veteran's PTSD, his only compensable service- connected disability. Statements from the veteran and his representative raise the issue of entitlement to a total rating based on individual unemployability resulting from service-connected disability. The veteran has not been accorded a psychiatric examination for rating purposes by the VA since July 1991. A Global Assessment of Functioning (GAF) score was not provided. When the veteran was released from a VA facility in August 1991, the veteran was given a GAF score of 41. However, as diagnoses included poly- substance abuse, anti-social and explosive personality disorder, and multiple Axis III diagnoses, in addition to PTSD, it is not possible to determine from this score the degree of impairment attributable to the PTSD. Subsequent medical evidence indicates continuing psychiatric impairment. The most recent medical evidence of record is a communication dated in January 1993 from the co-director of the PTSD program at the VA Medical Center, 4150 Clement Street, San Francisco, California, 94121. It was reported the veteran had been seen intermittently by the outpatient PTSD program at that facility since August 1991. The veteran's course had been marked by inconsistency in keeping to the treatment plans established. The case had been opened and closed twice; and a notation was made that the veteran was not currently in treatment with the program. Inpatient treatment for PTSD at the VA Medical Center, Menlo Park, California, was recommended, but the veteran only partially complied with guidelines set up as prerequisites for admission. The examiner reported a "chaotic psychosocial situation" during the course of his treatment of the veteran. The veteran was often homeless, occasionally got into fights with strangers, and admitted to the periodic use of marijuana. Additionally, there were some positive urine tests for opiate use. The examiner noted that although the veteran had undone all efforts to help him get into the inpatient program, he still might be able to get into the program should he demonstrate motivation to work on his problems. It was recommended the veteran contact Menlo Park outpatient services office to arrange for a screening interview. No subsequent medical evidence is of record. In light of the foregoing and the Board's duty to assist the veteran in the development of facts pertinent to his claim, as provided by 38 U.S.C.A. § 5107(a) (West 1991), the case is REMANDED to the RO for the following: 1. The RO should provide the veteran with an application for increased compensation based on individual unemployability due to service-connected disability. The RO should also request the veteran to provide the names and addresses of all health care providers who have treated him for psychiatric symptomatology since 1992 and specify the approximate dates of treatment, if possible. Then, after any necessary authorization is obtained from the veteran, the RO should obtain copies of any treatment records identified by the veteran. Of particular interest are any records subsequent to September 1992 from Swords to Plowshares, 400 Valencia Street, San Francisco, California, 94103. Also, the VA Medical Center, 4150 Clement Street, San Francisco, California, 94121, should be contacted and asked to provide complete clinical records pertaining to any treatment of the veteran at that facility since December 1992. 2. The RO should schedule the veteran for a comprehensive VA psychiatric examination. The examination should be conducted in accordance with the VA's Physician's Guide for Disability Evaluation Examinations (1985). The claims file must be made available to the examiner prior to the examination. The examiner should elicit from the veteran a detailed work history, as well as historical medical and social data. Any psychological testing deemed necessary to make a complete diagnostic evaluation and to differentiate symptoms attributable to PTSD from those due to other conditions should be accomplished. Primary personality disorders should be fully described and classified. The examiner should comment on the relationship, if any, between the veteran's PTSD symptoms and substance abuse. 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, effi- ciency and reliability levels which may be attributable to the PTSD (as distinct from impairment attributable to other conditions). The examiner should also assign a GAF score and explain what the assigned score represents. 3. Thereafter, the RO should readjudicate the veteran's claim, including the claim that he is unemployable as a result of his PTSD. If the psychiatric disability does not meet the schedular requirements of 38 C.F.R. § 4.16(c) (1994) for assignment of a total rating, the rating decision should reflect consideration of the applicability of 38 C.F.R. §§ 3.321(b)(1) and 4.16(b) (1994). Thereafter, if the benefit sought is not granted to the veteran's satisfaction, a supplemental statement of the case should be issued and he and his representative should be provided with the applicable time period in which to respond. The case should then be returned to the Board for further consideration, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. 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).