Citation Nr: 0005720 Decision Date: 03/02/00 Archive Date: 03/14/00 DOCKET NO. 92-07 532 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for neurological residuals, to include peripheral neuropathy, claimed as due to Agent Orange exposure. 2. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD). 3. Entitlement to a rating in excess of 50 percent for PTSD, since November 7, 1996. 4. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD B. Lemoine, Counsel INTRODUCTION The veteran had active duty from October 1963 to July 1966. The Board of Veterans' Appeals (Board) initially received this case on appeal from an October 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which granted the veteran's claim seeking entitlement to service connection for PTSD, assigning a 10 percent disability evaluation. The veteran appealed the assigned evaluation. A May 1995 rating decision of the RO increased the disability evaluation to 30 percent, effective to August 4, 1989, which was the original date of claim. The Board notes that a February 1999 rating decision further increased the disability evaluation for the veteran's PTSD to 50 percent, effective from November 7, 1996, which was the effective date of new regulations pertaining to all mental disorders. It is noted that the second issue now on appeal has previously been characterized in terms of the veteran's entitlement to an increased rating. More recently, however, the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (Court) has indicated that a distinction must be made between a veteran's dissatisfaction with the initial rating assigned following a grant of service connection (so- called "original ratings"), and dissatisfaction with determinations on later filed claims for increased ratings. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Inasmuch as the question currently under consideration was placed in appellate status by a notice of disagreement expressing dissatisfaction with an original rating, the Board has re-characterized the first issue on appeal as set forth on the title page hereinabove. In addition to the above, the Board has further recharacterized the previous appellate issue to specifically reflect an appeal concerning the 50 percent evaluation for the veteran's PTSD 50 percent, since November 7, 1996. The Board must note that where a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeal process has been concluded, the version most favorable to the veteran will apply. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). However it is appropriate that consideration under the revised rating schedule criteria, as in this case, not be undertaken before such criteria became effective. The effective date rule contained in 38 U.S.C.A. § 5110(g) prevents the application of a later, liberalizing law to a claim prior to the effective date of the liberalizing law, since the Secretary's legal obligation to apply the effective date of the revised regulations prevents the application of the liberalizing law rule stated in Karnas prior to that date. Accordingly, the Board has further recharacterized the original appellate issue to include entitlement to a rating in excess of 50 percent for PTSD, since November 7, 1996, as the second issue on appeal as set forth on the title page hereinabove. The fourth issue on appeal, entitlement to TDIU, was denied by a May 1995 rating decision which was appealed by the veteran. By way of procedural history, the Board notes that the issue of an increased evaluation for PTSD was previously remanded by the Board in April 1994. That claim and the veteran's claim of TDIU were denied by the Board in June 1996. The veteran appealed to Court and in October 1996, the parties moved jointly to vacate the Board's June 1996 decision and remand the case. The same month, the Court granted the motion and issued an order vacating the Board's 1996 decision and remanding the case for action in accordance with the joint motion. The case was then remanded again by the Board in June 1997. The case is now returned to the Board. Finally, it is noted that the veteran has also claimed service connection for neurological residuals of Agent Orange exposure, to include peripheral neuropathy. That claim was denied by a May 1995 rating decision. The veteran did timely indicate his notice of disagreement with that rating decision and the RO had previously been instructed by the Board to issue the veteran a statement of the case. Such statement of the case was first provided the veteran in October 1999. The veteran's substantive appeal was received in December 1999 and accordingly, that issue is now also developed for appellate review. (The issue of entitlement to service connection for neurological residuals, to include peripheral neuropathy, as due to Agent Orange exposure will be discussed in the body of this decision. See the Remand portion of this document for an explanation of further action required before the Board can adjudicate the remaining issues on appeal.) FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's appeal, regarding his claimed neurological residuals, to include peripheral neuropathy, as due to Agent Orange exposure, has been obtained by the RO. 2. Although there is medical evidence of record indicating that the veteran is currently diagnosed with a neurological disorder, to include chronic inflammatory demyelinating polyneuropathy and Guillain-Barre Syndrome, the first diagnosis of record was made many years after the veteran's service in Vietnam; and the veteran's diagnosed neurological disorders are not presumptively recognized by VA as etiologically related to exposure to herbicide agents used in Vietnam. 3. No medical evidence has been submitted to show that the veteran is suffering from peripheral neuropathy due to exposure to herbicide agents in service. 4. The veteran has not submitted competent evidence sufficient to justify a belief by a fair and impartial individual that he has presented a plausible claim of service connection for neurological residuals, to include peripheral neuropathy, due to exposure to herbicide agents. CONCLUSION OF LAW The veteran has not submitted a well-grounded claim of service connection for neurological residuals, to include peripheral neuropathy, due to exposure to herbicide agents. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a), (e) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background A review of the veteran's DD service records reveals that he served in Vietnam from August 1965 to July 1966 and he was awarded the Vietnam Service Medal and the Combat Infantry Badge. A careful review of the veteran's service medical records reveals that they are entirely negative for any evidence pertaining to the veteran's claimed neurological residuals, to include peripheral neuropathy, due to Agent Orange exposure. Likewise, they are negative for any neurological complaints. On separation examination in July 1966, the veteran had no pertinent complaints and all pertinent findings were normal. There are a significant amount of post-service medical records within the claims file, the vast majority of which, beginning in the 1980s and continuing to the present, pertain to the veteran's service connected PTSD. There is also a significant amount of medical evidence indicating that the veteran has been treated for chronic alcoholism. These records are not pertinent to the veteran's present claim regarding neurological residuals, to include peripheral neuropathy, due to herbicide agents and the Board need not report them in greater detail at this time. Review of more pertinent post-service medical records reveals that the veteran underwent a VA hospitalization in April 1967, when he was admitted, for the first time, because of loss of control of right facial muscles of one week duration. There was a diagnosis of Bell's Palsy of unknown etiology. It was further stated the veteran improved dramatically while hospitalized and was discharged and medication was prescribed. In May 1991, the veteran, accompanied by his then representative, appeared and presented testimony at a hearing on appeal before a VA hearing officer. The hearing was regarding the veteran's pending PTSD claim. However, during this hearing, the veteran also testified that was in receipt of payments from the Agent Orange Veteran Payment Program. (See Transcript, p. 6). A complete transcript of the testimony is of record. In June 1994, the veteran submitted his claim for a total disability rating due to individual unemployability and at that time also reported having neuropathy. The next medical record of any neurological complaint was during his VA examination for mental disorder in June 1994. At that time, it was reported that the veteran could not walk well, was wheelchair bound, and was receiving treatment for a diagnosis of demyelinating polyneuropathy. On general VA examination in June 1994, the veteran gave a history of having the onset of generalized weakness in 1982. Reportedly, he had recently been diagnosed with chronic inflammatory demyelinating polyneuropathy. The examination made a diagnosis of polyneuritis. There were also diagnoses of hypertension and diabetes mellitus. The examinations made no findings of peripheral neuropathy and no diagnosis of residuals to herbicide agents. Subsequently received were the private medical records from the Erie County Medical Center, indicating that in March 1992 the veteran had been diagnosed with acute demyelinating poly- radicular neuropathy (Guillain-Barre Syndrome). Subsequent records from the Erie County Medical Center and the Niagara Falls Medical Center indicated continued treatment for chronic inflammatory demyelinating polyneuropathy, but the records are entirely negative for any reference to a causal relationship to herbicide agents. The veteran acknowledged in a written statement, received in August 1994, that he had not been treated for peripheral neuropathy in service and that no diagnosis was made until he was treated by the Erie County Medical Center in 1992. Among the VA medical records within the claims file is a record of hospitalization dated from April 1993 to September 1994 that indicated a diagnosis of chronic inflammatory demyelinating polyneuropathy, among other disorders. In May 1995, the veteran submitted a letter in which he reported that his unit served in areas that were heavily sprayed with Agent Orange. The veteran underwent a VA examination for PTSD in April 1998, during which he reported a history of peripheral neuropathy in his legs. The examination was limited to a psychiatric and psychological evaluation of the veteran's PTSD, but a diagnosis of peripheral neuropathy was made, apparently based upon history provided. Received in October 1998 were records from the Social Security Administration pertaining to the veteran. These indicated that the veteran had been considered disabled since December 1989 with a primary diagnosis of depression and substance abuse and the date of onset of disability was October 1988. There was also subsequent evidence of record of chronic inflammatory demyelinating polyneuropathy and Guillain-Barre Syndrome. There was no medical evidence of any diagnosis of residuals to exposure to herbicide agents. II. Analysis The veteran and his representative contend, in essence, that service connection is warranted for neurological residuals, to include peripheral neuropathy, claimed as due to Agent Orange exposure. The veteran has not contended that he suffered from peripheral neuropathy within one year of his service in Vietnam. In contrast, the veteran has given a history on numerous occasions of having first experienced weakness of the extremities sometimes in the 1980s and having first received a diagnosis of a neurological disorder when treated by the Erie County Medical Center in 1992. The veteran has argued that he was exposed to a large amount of Agent Orange during his service and that this exposure is the cause of his current neurological disorders. The threshold question which the Board must address in this case is whether the appellant has presented a well-grounded claim. A well-grounded claim is one which is plausible. If he has not, the claim must fail and there is no further duty to assist in the development of the claim. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet. App. 78 (1990). This requirement has recently been reaffirmed by the United States Court of Appeals for the Federal Circuit, in its decision in Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). That decision upheld the earlier decision of the United States Court of Appeals for Veterans Claims which made clear that it would be error for the Board to proceed to the merits of a claim which is not well grounded. Epps v. Brown, 9 Vet. App. 341 (1996). The United States Supreme Court declined to review the case. Epps v. West, 118 S. Ct. 2348 (1998). A well-grounded claim requires more than an allegation; the claimant must submit supporting evidence. Furthermore, the evidence must justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Also, in order for a claim to be well-grounded, there must be competent evidence of a current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well- grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). As explained below, the Board finds that the veteran has not presented a well-grounded claim of service connection for neurological residuals, to include peripheral neuropathy, claimed as due to Agent Orange exposure. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110. In addition, certain diseases, when manifest to a degree of 10 percent or more within one year after the veteran's military service ended, may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d). A chronic, tropical, or prisoner-of-war related disease, or a disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309 will be considered to have been incurred in service under the circumstances outlined in this section even though there is no evidence of such disease during the period of service. No condition other than one listed in 38 C.F.R. § 3.309(a) will be considered chronic. 38 U.S.C.A. §§ 1101, 1112, 1113, 1116; 38 C.F.R. § 3.307(a). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, and has a disease listed at 38 C.F.R. § 3.309(e), shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The regulation, further, specifically defines the term "acute and subacute peripheral neuropathy" to mean a transient neuropathy which appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. 38 C.F.R. § 3.309(e), Note 2. The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed.Reg. 341-346 (1994). See also 61 Fed.Reg. 41,442-41,449, and 61 Fed.Reg. 57,586-57,589 (1996). Notwithstanding the foregoing presumption provisions, which arose out of the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984), and the Agent Orange Act of 1991, Pub. L. No. 102-4, § 2, 105 Stat. 11 (1991), the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom. Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). See also Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). However, where the issue involves a question of medical diagnosis or causation as presented here, medical evidence which indicates that the claim is plausible is required to set forth a well-grounded claim. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Having discussed the applicable laws and regulations, and having reviewed all of the evidence of record, the Board will first address the question of whether the veteran experienced an exposure to herbicide agents in service. In this regard, the Board finds it is clear that the veteran served in Vietnam. The Board further notes that there is no competent evidence of record that the veteran was diagnosed with acute and subacute peripheral neuropathy as defined within Note 2 of 38 C.F.R. § 3.309(e). In this regard, it is noted that the veteran does not currently have a diagnosis of any disorder presumptively recognized by VA as etiologically related to exposure to herbicide agents used in Vietnam. As the veteran does not have a diagnosis for one of the disorders specifically enumerated in 38 C.F.R. § 3.309(e), the presumption of exposure to Agent Orange or other herbicide agents is unavailable to him. See McCartt v. West, 12 Vet. App. 164 (1999). The Board notes that VA Adjudication Procedure Manual, M21-1, Part VI, para. 7.20b previously contained a more liberal interpretation of the presumption of exposure, stating that "unless there is affirmative evidence to the contrary, a veteran who served on active duty in the Republic of Vietnam during the Vietnam era is presumed to have been exposed to an herbicide agent." However, pursuant to McCartt, that M-21-1 provision has been revised in order to conform with the McCartt decision, and the more liberal presumption is no longer available to establish exposure. The Board notes, however, that the veteran has contended within his claim that he was exposed to Agent Orange in service during combat, and the Board further notes that the veteran was awarded a Combat Infantry Badge, supporting his history of having experienced exposure to herbicide agents in the field. Furthermore, solely for purposes of determining the well-groundedness of his claim, these contentions will be considered credible by the Board. See King, supra. However, even conceding for this limited purpose that the veteran experienced exposure to herbicide agents in service, the Board notes that there is no credible evidence of record indicating that the veteran was diagnosed with acute and subacute peripheral neuropathy as one of the conditions specified within 38 C.F.R. § 3.309(e), within the required presumptive time period. In this regard, the Board notes that the veteran's service in Vietnam ended in July 1966. In order for the veteran to be granted presumptive service connection for acute and subacute peripheral neuropathy, as defined by 38 C.F.R. § 3.309(e), the diagnosis should have become manifest to a degree of 10 percent or more by July 1967. See 38 C.F.R. § 3.307(a)(6)(ii). (Any diagnosis made after July 1967 would not establish presumptive service connection.) In this regard, the Board has also carefully reviewed the veteran's treatment in April 1967, when he was diagnosed with Bell's palsy following loss of control of the right facial muscles. The Board notes however, that this incident resolved upon hospitalization and there is no competent evidence linking this incident of treatment to any of the currently diagnosed neurological disorders, nor was there any diagnosis of peripheral neuropathy at that time. More recent medical evidence clearly shows that the veteran is currently diagnosed with a neurological disorder, alternately identified as either chronic inflammatory demyelinating polyneuropathy or Guillain-Barre Syndrome. However, these diagnoses were not made until many years after the veteran's service in Vietnam. There is simply no competent evidence of record of a diagnosis of peripheral neuropathy within the presumptive period of service connection before July 1967. Nor is there competent evidence of any other required diagnosis within the presumptive period. Nor is there any medical evidence of record suggesting a connection between exposure to herbicide agents and the veteran's currently diagnosed chronic inflammatory demyelinating polyneuropathy and Guillain-Barre Syndrome. Although the medical record clearly indicates the veteran has been diagnosed with these neurological disorders, the first competent evidence of such a diagnosis was in 1992, some 26 years after his service. Furthermore, all medical records, to include all VA medical records and all private medical records, are entirely negative for any discussion of a nexus between the veteran's currently diagnosed chronic inflammatory demyelinating polyneuropathy and Guillain-Barre Syndrome and his claimed exposure to herbicide agents. Therefore, the claim is not well-grounded. As for the veteran's May 1991 testimony indicating his receipt of payments from the Agent Orange Veteran Payment Program, the Board notes that documents regarding the veteran's acceptance in the Agent Orange Veteran Payment Program do not address the medical conditions at issue and do not serve to make the claim well grounded. Receipt of compensation under the Agent Orange Veteran Payment Program, which is a nongovernmental, nonprofit entity, is based upon standards very different than those required to establish service connection. See Brock v. Brown, 10 Vet. App. 155 (1997); Viglas v. Brown, 7 Vet. App. 1 (1994). Thus, the Board need not further consider the veteran's receipt of payments under this program as they do not make his claim well-grounded and there is no need to seek further records of such payment by remand. The Board has also carefully considered the veteran's contentions that his Agent Orange exposure is the only possible explanation for his current neurological disorders. The Board notes, however, that inasmuch as the veteran is offering his own medical opinion and diagnoses, the record does not indicate that he has any professional medical expertise. See Bostain v. West, 11 Vet. App. 124, 127 (1998) ("lay testimony . . . is not competent to establish, and therefore not probative of, a medical nexus"); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (1998). See also Espiritu v. Derwinski, 2 Vet. App. 492 (1992); Moray v. Brown, 5 Vet. App. 211 (1993); Grottveit v. Brown, 5 Vet. App. 91 (1993). As noted previously, Caluza requires for a claim to be well grounded, competent evidence of a current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). The veteran has provided competent medical evidence that he was diagnosed with chronic inflammatory demyelinating polyneuropathy and Guillain-Barre Syndrome many years after his service. The veteran has also provided lay evidence, in the form of his contentions, that he experienced exposure to herbicide agents in service. However, there is no medical evidence that the veteran's diagnosed disorder is etiologically related to exposure to herbicide agents in service. As such evidence has not been presented here, the veteran has not submitted a well-grounded claim of service connection. Finally, the Board is satisfied that the RO took all reasonable steps to properly develop the veteran's claim. The veteran has not informed VA of the existence of any available evidence that would render his claim well grounded. He has not contended that any further relevant records exist. Indeed, the veteran has acknowledged in writing that there were no medical treatment records prior to 1992; and it appears from the record that all pertinent subsequent treatment records are within the claims folder. The Board therefore finds that no further action is warranted relative to the development of the appellant's claim, based upon the information currently of record. Hence, the Board concludes that there are no additional pertinent records of treatment which are not in the claims folder and would be available. See Counts v. Brown, 6 Vet. App. 473, 477 (1994). Therefore, under the circumstances of this case, the appellant's application is not incomplete, and VA has not been put on notice that other relevant evidence exists, or could be obtained, which, if true, would make the claim "plausible." Robinette v. Brown, 8 Vet. App. 69, 80 (1995). Moreover, VA is not required to notify the veteran of particular evidence needed to make his application complete if the Department has not reasonably had notice of the existence of such evidence. McKnight v. Gober, 131 F.3d 1483, 1485 (Fed. Cir. 1997). Consequently, a remand for additional evidentiary development is not warranted under the facts of this case. ORDER Entitlement to service connection for neurological residuals, to include peripheral neuropathy, claimed as due to Agent Orange exposure is denied, as the claim is not well-grounded. REMAND Review of the evidentiary record reveals that the veteran has a prolonged history of psychiatric treatment for depression and alcoholism, as well as for PTSD. At times he has also been diagnosed with bipolar disorder. A June 1989 VA medical record notes a positive family history for mental illness. The veteran has been determined by the Social Security Administration to be totally disabled due to depression and substance abuse. The Board also notes that the veteran has a variety of other physical ailments. For example, a record of VA hospitalization from April to September 1994 noted diagnoses of chronic immune demyelinating polyneuropathy, congestive heart failure, and cardiomyopathy. The veteran also suffers from hypertension. There are extensive medical records within the claims file, many of which pertain to treatment of the veteran's complaints of weakness associated with his chronic immune demyelinating polyneuropathy. There are also numerous medical records which describe the veteran as unemployable, although many of these records discuss his unemployability in terms of his non-service connected physical disabilities. In order to clarify the nature and extent of the veteran's service connected PTSD and also in order to clarify the cause of his unemployability, his claims were remanded by the Board in June 1997. The remand requested that the veteran be afforded a VA social and industrial survey to assess his employment history and day-to-day functioning. The remand also requested that the veteran be scheduled for a VA examination for purposes of evaluation of his disorders. In pertinent part, it was requested that the examiner provide an opinion on the overall extent of "the disability," that is, the disability due to PTSD and any other diagnosis that has effects that cannot be dissociated from PTSD; and that the examiner opine on the extent to which disability due to PTSD affects occupational and social functioning. Upon review of the subsequent development of the claim, the Board notes that the veteran did undergo a VA examination in April 1998, which apparently included a VA social and industrial survey. The Board further notes that the examination diagnosed chronic delayed PTSD. However, the examination offered no discussion of the veteran's other previously diagnosed mental disorders, and whether the veteran's symptoms could be differentiated from his service connected PTSD. Furthermore, although the examination described the veteran as quite impaired in several areas and as unemployable, there was no discussion as to whether the veteran was unemployable due solely to the PTSD, or due to other non-service connected disorders. The examiner failed to discuss the veteran's many non-service-connected ailments and disorders, and the impact that his non-service-connected conditions might have on his overall well-being and ability to hold a job. The Board notes that the examination described the veteran's level of impairment, with a GAF score of 50. According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), a GAF of 50 represents serious symptoms or serious impairment in social, occupational, or school functioning. In addition to the above, the Board notes that the VA examination of the veteran made reference to his continued ongoing VA outpatient treatment. However, it is unclear that the veteran's recent VA outpatient treatment records were obtained by the RO for the claims file. Because the VA examiner who last examined the veteran did not provide an adequate analysis in light of the foregoing, and because of the need to obtain additional medical records, this matter must be remanded for a new examination. 38 C.F.R. §§ 4.2, 19.9 (1999). In this regard, the Board notes that we may consider only independent medical evidence to support our findings, and must cite to competent evidence of record to support our conclusions. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991), and Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Therefore, as the Board is unable to determine, on our own, whether certain psychiatric manifestations emanate from the service-connected mental disability, or from other non- service-connected disability; we must rely upon medical expertise in this regard. A remand is necessary in this case so that the veteran may be scheduled for another VA psychiatric examination to determine his current diagnosis and assess any manifestations thereof. In order to be absolutely clear, the Board emphasizes that the objective of a further examination should be to obtain clarifying data as to the degree of impairment from the veteran's service-connected PTSD, including a determination of what psychiatric symptomatology is directly attributable to the service-connected disorder. The impact of any non- service-connected disorders should be addressed, and the veteran's VA outpatient treatment records and prior medical records must also be addressed. This in turn, will permit an accurate assessment of the current severity of the veteran's service-connected disorder, as opposed to symptomatology attributable to non-service-connected disorder(s). VA has a duty to assist a veteran in developing facts pertinent to a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103, 3.159 (1998). That duty includes obtaining medical records and medical examinations where indicated by the facts and circumstances of an individual case. See Murphy v. Derwinski, 1 Vet. App. 78 (1990); Littke v. Derwinski, 1 Vet. App. 90 (1990). In addition to the above, the Board notes that the rating criteria have been changed for all psychiatric disorders, effective on November 7, 1996. As previously noted, when the regulations concerning entitlement to a higher rating are changed during the course of an appeal, the veteran is entitled to resolution of his claim under whichever criteria are to his advantage. Karnas v. Derwinski, 1 Vet. App. 308 (1991). Although the RO has indicated in the prior supplemental statement of the case that both the old and new criteria were considered, the Board notes for the RO's benefit that the veteran continues to be entitled to the resolution of his claim under whichever criteria are more favorable. See also DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). The RO should also consider the application of a "staged rating" to the veteran's original claim in accordance with Fenderson, 12 Vet. App. 119. Accordingly, further appellate consideration will be deferred and the case is REMANDED to the RO for the following action: 1. The RO should take appropriate steps in order to contact the veteran and obtain the names and addresses of all medical care providers (VA and non-VA) who have recently treated the veteran for his service-connected PTSD. After securing the necessary releases, the RO should obtain any outstanding records. 2. The RO should take the appropriate steps to secure copies of all of the veteran's VA treatment records, not already of record, and associate them with the claims folder. 3. The RO should then schedule the veteran for a VA psychiatric examination, for the purpose of assessing the degree of social and industrial impairment resulting from his service-connected PTSD. Before examining the veteran, the examiner should carefully review the veteran's claims folder, and review both the old and the new rating criteria for mental disorders. If appropriate, all indicated tests to include psychological testing should be conducted in association therewith. The findings of the examiner must address the presence or absence of the specific criteria set forth in the rating schedule. The examiner should also be requested to assign a score on the Global Assessment of Functioning (GAF) scale, and to describe what the score means for the veteran in terms of his psychological, social, and occupational functioning. In addition, the symptomatology directly attributable to the veteran's service- connected disorder should be fully discussed, and the presence of any other existing mental disorders should be evaluated. To the extent possible, symptoms attributable to any other disorder should be distinguished from those associated with the service- connected disorder. The psychiatric examiner should comment on the interference with gainful employment attributable solely to the service- connected disorder, as opposed to any mental or physical non-service connected disorder. If such distinction is not possible, the examiner should so specifically indicate. A complete rationale for all opinions expressed must be provided. 4. With regard to all the instructions set forth above, the veteran is advised of his obligation to cooperate by providing the requested information to the extent possible and by reporting for the scheduled examination, and his failure to cooperate may result in adverse action pursuant to 38 C.F.R. § 3.158 and § 3.655. 5. After all the development requested hereinabove has been completed, then the RO should again review all the veteran's claims. The RO should again consider the evaluation of the veteran's PTSD disorder under both the old and new rating criteria and rate in accordance with the guidance expressed by the Court in Karnas, and Fenderson. The RO should also consider the veteran's entitlement to TDIU. If any determination remains unfavorable to the veteran, the RO should furnish him and his representative with a supplemental statement of the case, in accordance with 38 U.S.C.A. § 7105. Thereafter, the veteran and his representative should be given the opportunity to respond. The case should be returned to the Board for further appellate consideration, if otherwise in order, following appropriate appellate procedure. By this REMAND the Board intimates no opinion, either legal or factual, as to the ultimate determination warranted in this case. The purpose of this REMAND is to further develop the record. No action is required by the veteran until he receives further notice. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. LAWRENCE M. SULLIVAN Member, Board of Veterans' Appeals 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) (1998).