BVA9502780 DOCKET NO. 93-10 885 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to an increased rating for psychoneurotic disability, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESSES AT HEARING ON APPEAL The appellant and Virgil Hudson ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel REMAND The veteran had active service from April 1971 to June 1972. This appeal arises from a September 1991 rating decision of the Atlanta, Georgia, Regional Office (RO). The Department of Veterans Affairs (VA) has a duty to assist the veteran in the development of facts pertaining to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals (Court) has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal. The duty to assist is neither optional nor discretionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). The veteran has been receiving continuing treatment for his psychoneurosis at the Augusta VA outpatient clinic; complete records should be obtained from that facility. The duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). This is to ensure that the evaluation of a disability is a fully informed one. The severity of psychiatric disability is based upon actual symptomatology as it affects social and industrial adaptability. See 38 C.F.R. §§ 4.129, 4.130 (1993). Since the last VA psychiatric rating examination in August 1991, the veteran has had three lengthy VA inpatient treatment periods to include a period from June to September 1992. The September 1992 discharge summary indicates that the veteran was considered to be unemployable. His complaints included increased anxiety, depression, explosive anger, nightmares, flashbacks, and an inability to deal with every day situations. It was reported that the veteran had been in receipt of Social Security Administration (SSA) disability benefits since 1986. In view of the foregoing, the Board is persuaded that the veteran should be afforded a further VA psychiatric examination in connection with this appeal. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and obtain the names and addresses of all mental health care providers from whom he has received treatment in recent years. Thereafter, the RO should obtain legible copies of all records which have not already been obtained, to include those from the Augusta VA outpatient clinic. Once obtained, all records must be associated with the claims folder. 2. The RO should contact the SSA and obtain legible copies of the decision which awarded disability benefits to the veteran and the medical records upon which that decision was based. All records should be associated with the claims folder. 3. Following completion of the above development, the veteran should be afforded a comprehensive VA examination in psychiatry. This study should be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, should be conducted. The claims file must be made available to and reviewed by the examiner prior to the examination. The disability should be evaluated in relation to its history, with emphasis upon the limitation of activity imposed by the service-connected psychoneurosis. The examiner should assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual For Mental Disorders, and explain what the assigned score represents. 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, efficiency and reliability levels which may be attributable to the psychoneurosis (as distinct from impairment attributable to other conditions). 3. Following completion of the foregoing, the RO must review the claims folder and ensure that the foregoing development has been completed in full. If any development is incomplete, appropriate corrective action should be implemented. When the requested development is fully completed, the RO should readjudicate the veteran's claim. The rating decision should reflect consideration of the applicability of the provisions of 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.129, and 4.130. If the claim is not granted to the veteran's satisfaction, he and his representative should be furnished with a supplemental statement of the case. They should then be afforded the applicable time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. 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).