BVA9507823 DOCKET NO. 93-16 187 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased evaluation for service-connected post traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Christopher P. Kissel, Associate Counsel REMAND The appellant had active service in the United States Marine Corps from June to November 1980, and from December 1982 to May 1986. This matter came before the Board of Veterans' Appeals (the Board) on appeal from a July 1992, rating decision of the Columbia, South Carolina, Department of Veterans Affairs Regional Office (VARO). Review of the evidence of record reveals that the various psychiatric clinicians who have examined and treated the appellant have not objectively related his PTSD symptomatology to the level of impairment, if any, pertinent to his overall "social and industrial adaptability," as that term is construed in the VA's Schedule for Rating Disabilities. See 38 C.F.R. § 4.129 (1994). In view of this finding, and to ensure compliance with a recent decision of the United States Court of Veterans Appeals, Massey v. Brown, No. 93-135 (U.S. Vet. App. Dec. 6, 1994), the Board concludes that additional medical and evidentiary development is necessary in this case. In view of the appellant's contentions concerning his inability to work due to the severity of his service-connected PTSD, the Board believes that a thorough examination is necessary to resolve the issue presented on appeal. Review of the record indicates that the appellant's PTSD disability was previously evaluated by VA in November 1991, prior in time to when he filed his current claim seeking increased compensation benefits (June 1992). The duty to assist the appellant includes the duty to develop the pertinent facts by conducting a current and thorough medical examination. See Littke v. Derwinski, 1 Vet.App. 90 (1991). With respect to additional evidentiary development, the record reflects that the appellant was seen by J. F. Abess, M.D., and a social worker, J. Sullivan, MSW, on a number of occasions in 1992, for treatment of his PTSD symptoms. See Dr. Abess's letter of November 23, 1992. However, complete photocopies of any outpatient/progress reports relative to these clinicians' treatment of the appellant have not been associated with the claims folder. Further, the Board notes that the appellant participated in a VA vocational rehabilitation program in 1990; however, his Chapter 31 file was not associated with the record on appeal and considered in conjunction with his claim. In addition, the record indicates that the appellant was awarded Social Security Administration (SSA) disability benefits in May 1992, based, at least in part, upon his service-connected PTSD. VARO should ensure that any pertinent medical records connected with the disposition of that award which are not currently of record be obtained and associated with the claims folder. The Board believes that requisition of these records is necessary for the proper adjudication of the appellant's claim. Decisions of the Board must be based on all of the pertinent evidence available. 38 U.S.C.A. § 7104(a) (West 1991) and Gilbert v. Derwinski, 1 Vet.App. 78 (1990). The duty to assist the appellant in the development of his claim includes the duty to request information which may be pertinent to the claim. 38 U.S.C.A. §§ 5106, 5107(a) (West 1991). In addition, the Board notes that additional evidence, mostly duplicative in nature but consisting of a 1995 hospital report not previously reviewed by VARO, was submitted directly to the Board by the appellant following certification of the appeal. This evidence should be considered by VARO in conjunction with the readjudication of his claim. Accordingly, this case is REMANDED for the following action: 1. The Chapter 31 Vocational Rehabilitation Folders, including the Counseling Folder, should be obtained, and legible copies of these files or the files themselves should be associated with the claims folder. 2. VARO should request complete, legible copies of all treatment reports from Dr. Abess and a private social worker, J. Sullivan, dating from 1992 to the present time after securing appropriate releases from the appellant. All attempts to secure these records should be undertaken. All records received in response to this request should be associated with the claims folder. 3. VARO should obtain from the Social Security Administration any medical records not currently associated with the claims folder which were relied upon concerning that claim. 4. A social and industrial survey should be conducted. It should be ascertained if the veteran is working. Family members, former coworkers, members of the community and the veteran should be interviewed. The purpose of the survey is to obtain information upon which to assess the impact of the service- connected psychiatric disorder on the veteran's ability to secure or follow a substantially gainful occupation. 5. After completion of the above development, VARO should schedule the appellant for a comprehensive VA psychiatric examination. This study must be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, must be conducted. The results of the testing should be reviewed by the examiner prior to completion of the report. The claims folder must be made available to and reviewed by the examiner prior to the requested study. The report of examination should contain a detailed account of all manifestations of psychiatric pathology found to be present. If there are different psychiatric disorders, the psychiatrist should reconcile the diagnoses and should specify which symptoms are associated with and which disorders are part of or caused by the service-connected disorder. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The physician should comment on the opinions expressed by John F. Abess, M.D. in November 1992 and Mark Fossey, M.D. in March 1992 with respect to the veteran being totally disabled. The examiner should describe how the symptoms of the service-connected psychiatric disorder affect his social and industrial capacity and assess their impact on the veteran's ability to obtain and maintian gainful employment. The examiner must assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (3rd ed. rev., 1987), and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. 6. Following completion of the foregoing, VARO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examination does not include all test reports, special studies or opinions requested, appropriate corrective action is to be implemented. 7. The VARO should formally adjudicate service connection for any psychiatric disorder other than post-traumatic stress disorder found on examination. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. JAN DONSBACH 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) (1994).