Citation Nr: 0002835 Decision Date: 02/04/00 Archive Date: 02/10/00 DOCKET NO. 97-02 150 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Determination of a proper initial rating for post-traumatic stress disorder (PTSD), currently assigned a 30 percent evaluation. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Wm. Kenan Torrans, Associate Counsel INTRODUCTION The veteran served on active duty from August 1967 to May 1970. This matter arises from a July 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which granted service connection for PTSD, and assigned an initial evaluation of 10 percent, effective from May 29, 1996. The veteran filed a timely appeal, but before the case was referred to the Board of Veterans' Appeals (Board), he was granted an increased initial evaluation of 30 percent for his PTSD by a January 1998 rating decision. The veteran has continued his appeal, contending, in substance, that the severity of his PTSD warrants an initial evaluation in excess of 30 percent. The case has been referred to the Board for resolution. REMAND The veteran's original claim for service connection for PTSD was received by the RO in May 1996. As noted, service connection for the veteran's PTSD was initially granted by a July 1996 rating decision, and a 10 percent evaluation was assigned, effective from May 29, 1996. The veteran filed a timely appeal, and before the case was referred to the Board, his initially assigned 10 percent evaluation was increased to 30 percent, by a January 1998 rating decision. The veteran now claims that he is unemployable as a result of his service-connected PTSD, and asserts that the severity of that disability is greater than that reflected by the initially assigned 30 percent evaluation. Therefore, he contends that an initial evaluation in excess of 30 percent is warranted. A review of the veteran's contemporaneous clinical treatment records discloses that he has been hospitalized on several occasions in May and June 1996, May 1997, and August 1997 primarily for what was diagnosed as Axis I polysubstance abuse. In May and June 1996, the veteran was also noted to have some problems related to PTSD and depression, but the extent to which his functional impairment was incurred as a result of PTSD symptoms or his polysubstance abuse was not indicated. However, the records show that he was primarily treated for heavy cocaine and alcohol abuse. The veteran was also noted to have been recently fired from his job of 24 years as a Chicago Transit Authority bus driver, following testing positive for drugs. At that time, he was noted to be employed as a limousine driver, and that he intended to resume such employment upon being discharged from treatment. At the time of his discharge from treatment, the veteran was diagnosed with an Axis V Global Assessment of Functioning (GAF) score of 65. Under the Diagnostic Statistical Manual, 4th Edition (DSM-IV), such a GAF score is suggestive of some mild symptoms of a psychiatric disorder (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful social relationships. The Board observes that upon admission for treatment in May 1997, the veteran was diagnosed with an Axis V GAF score of 35-40. Under DSM-IV, such a GAF score is suggestive of some impairment in reality testing or communication, or major impairment in several areas. However, upon his discharge from treatment, the veteran was diagnosed with an Axis V GAF score of 60, suggesting moderate symptoms of a psychiatric disorder, or moderate difficulty in social, occupational, or school functioning. The veteran claimed to have had suicidal ideation in the past, but none at the time of discharge. He was characterized as coherent with good contact with reality. The report of the August 1997 inpatient treatment also shows that the veteran was admitted with a lower GAF score of 45- 50, indicating serious symptoms of a psychiatric disorder, but that on discharge, he had an Axis V GAF score of 60. Again, he was diagnosed with Axis I polysubstance disorder and PTSD, but the hospitalization report failed to indicate the extent to which his functional impairment was the result of PTSD or was the result of polysubstance abuse. The veteran underwent two VA rating examinations, in June 1996 and in January 1997. The report of the June 1996 rating examination includes notations of such PTSD-related symptomatology as intrusive recollections, nightmares, avoidance, diminished activities, and estrangement from others. In addition, the examiner stated that the veteran had been seen on an inpatient basis in May 1996 for treatment for substance abuse and depression. Without discussing the veteran's level of functional impairment, the examiner concluded with an Axis I diagnosis of PTSD, and an Axis V diagnosis of "fair functioning." The examiner did not offer any GAF score at that time. The report of the January 1997 VA rating examination likewise failed to include any Axis V GAF score, and the examiner again only noted that the veteran had "fair functioning." Of some note, the examiner offered an Axis I diagnosis of schizo-affective disorder, depressed type, and polysubstance abuse. He did not include PTSD among his listed Axis I diagnoses, or offer any explanation for the conclusions reached in his examination report. However, a subsequent statement dated in October 1997 indicates that the veteran had a GAF score of 50, and while noting the veteran's diagnoses of Axis I PTSD and polysubstance abuse, did not indicate the extent to which the veteran's functional impairment was due to polysubstance abuse and the extent to which such impairment was due to PTSD. Documents dated in February 1998 were received from the Social Security Administration (SSA), which indicated that the veteran was considered to be disabled since May 2, 1996, and was unable to work due to "PTSD, drug abuse, and a skin disorder." It was determined that the veteran's PTSD and depression significantly limited his ability to "do basic work activity," and were, therefore, "severe" under the Social Security Act and Regulations. The Board acknowledges the SSA examiner's findings, but also notes that such findings appear to be contraindicated by the medical evidence currently of record, primarily consisting of the veteran's inpatient treatment records for polysubstance abuse. In any event, after a review of the evidence, the Board must conclude that the VA rating examinations of June 1996 and January 1997 are not adequate to assess the level of functional impairment the veteran experiences due to his PTSD, particularly in view of the extensive treatment he has undergone for his polysubstance abuse problems, as contrasted with the conclusions reached in the February 1998 SSA documents. Accordingly, the Board finds that additional development of the case must be undertaken before the case can be properly adjudicated. Specifically, the veteran should be scheduled to undergo a VA rating examination to assess the degree of functional impairment resulting from his PTSD, as well as to assess the degree of impairment resulting from his polysubstance abuse. Following completion of this development, the RO should readjudicate the veteran's claim for determination of a proper initial rating for his PTSD taking into account all pertinent statutes and regulations. In this regard, the Board notes that the veteran's claim upon which this appeal is based was received in May 1996. Accordingly, all evidence received pursuant to this claim, dating from the time the claim was received in May 1996 must be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). Therefore, in order to fully and fairly adjudicate the veteran's claim, the case is REMANDED to the RO for the following action: 1. After obtaining any necessary authorization, the RO should obtain and associate with the claims file any records of treatment for the veteran's PTSD dated since the time of the last request for such information. 2. The veteran should then be scheduled to undergo a VA rating examination to evaluate the severity of his service- connected PTSD by an examiner who has not previously examined the veteran, if possible. The veteran's claims folder should be made available to the examiner to be reviewed in advance of the scheduled examination. The examiner is requested, in his evaluation of the veteran's PTSD, to distinguish between the symptoms and functional impairment incurred as a result of the veteran's polysubstance abuse disorder, and those symptoms and the degree of functional impairment which are determined to be due solely to his service-connected PTSD. The examiner is requested to offer an opinion as to the types of employment in which the veteran is found to be capable of engaging. To the extent that the veteran may be found to be incapable of obtaining or retaining gainful employment, the examiner is requested to indicate the degree to which such unemployability is the result of the veteran's PTSD and the degree to which such unemployability is the result of nonservice-connected disorders including polysubstance abuse. In addition, the examiner is requested to include in his final diagnosis an Axis V GAF score, as set forth in DSM-IV, reflecting the degree of functional impairment caused by the veteran's PTSD. If possible, the examiner is requested to indicate the extent to which any functional impairment is due to polysubstance abuse. The report of the examination, which should be legibly typewritten, should also include a complete rationale for all opinions expressed. 3. The RO should review the report of the rating examination, and ensure that it complies with the Board's directives set forth above. If it does not, the RO should undertake all appropriate action necessary to ensure compliance with this REMAND. Thereafter, the RO should adjudicate the issue of entitlement to an initial evaluation in excess of 30 percent, taking into account all relevant statutes and regulations, including the provisions of Karnas v. Derwinski, 1 Vet. App. 308 (1991) and Rhodan v. West, 12 Vet. App. 55 (1998). If the determination remains unfavorable to the veteran, the RO should furnish a supplemental statement of the case, and provide an opportunity to respond prior to referring the case back to the Board for further action. The purpose of this REMAND is to obtain additional development. The Board does not intimate any opinion as to the merits of this case, either favorable or unfavorable, at this time. The veteran is free to submit any additional evidence he desires to have considered in connection with the present appeal. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the veteran until he is notified. BRUCE KANNEE 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).