BVA9504760 DOCKET NO. 93-09 893 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a nervous disorder, to include post traumatic stress disorder (PTSD). 2. Entitlement to service connection for headaches. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Brynn K. Bloomgren, Associate Counsel INTRODUCTION The appellant had active service from December 1945 to December 1948. This matter came before the Board of Veterans' Appeals (hereinafter the Board) on appeal from a May 1992 rating decision of the St. Petersburg, Florida, Regional Office (hereinafter RO) of the Department of Veterans Affairs (hereinafter VA), which denied entitlement to service connection for a nervous disorder, to include PTSD, and for headaches. It is unclear whether the veteran intends to appeal the RO's denial of service connection for hypertension and heart disease. These issues are not in appellate status at this time, and we refer them to the RO for appropriate action. REMAND The veteran contends that he suffered a nervous breakdown and was hospitalized in a military infirmary for approximately two and a half weeks in Germany following World War II. The RO requested the veteran's service medical records from the National Personnel Records Center (NPRC) in St. Louis, Missouri, in January 1992. While the veteran's entrance and separation examination reports were obtained, other reports were not located. It is possible that the veteran's remaining service medical records were destroyed in a fire at the NPRC in July 1973. The RO has not made further efforts to verify the claimed hospitalization. The veteran, by his representative, requests that the Army Surgeon General's Office (SGO) be contacted and that the service unit records be searched to verify the claimed hospitalization. When a veteran's service records have been destroyed, the VA has an obligation to search for alternative medical records which support the veteran's case. See Cuevas v. Principi, 3 Vet.App. 542 (1992); O'Hare v. Derwinski, 1 Vet.App. 365 (1991). We observe that service connection may also be shown through evidence other than service medical records, such as private medical records, "buddy" statements, and personal testimony. Smith v. Derwinski, 2 Vet.App. 147 (1992); 38 C.F.R. § 3.303(a) (1994). Regarding the claim for service connection for PTSD, recent Court of Veterans Appeals (Court) cases have further articulated the development and jurisdictional scope of PTSD claims. The Court has held that the evidence necessary to confirm the existence of a stressor depends upon whether the veteran "engaged in combat with the enemy," which must be determined through recognized military citations or other service department evidence. Zarycki v. Brown, 6 Vet.App. 91 (1993). The Court has further held that the mere presence in a combat situation is not sufficient to show that he was engaged in combat with the enemy. Wood v. Derwinski, 1 Vet.App. 190 (1991) (affirmed on reconsideration, 1 Vet.App. 406 (1991)). In this case, since the veteran's service records do not contain any reference to combat citations, there is no objective evidence that he "engaged in combat with the enemy," and corroboration of alleged stressors must be sought. Once the existence of a stressor is established, the sufficiency of the stressor must be established by a medical determination. West v. Brown, 7 Vet.App. 70 (1994). The question of the existence of an event claimed as a recognizable stressor must be resolved by adjudicatory personnel. (For the most recent description of what constitutes a stressor, see the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, (Fourth Ed. 1994) or DSM-IV). If the adjudicators conclude that the record establishes the existence of such a stressor or stressors, then and only then, the case should be referred for a medical examination to determine the sufficiency of the stressor and as to whether the remaining elements required to support the diagnosis of post-traumatic stress disorder have been met. In such a referral, the adjudicators should specify to the examiner precisely what stressors have been accepted as established by the record, and the medical examiners must be instructed that only those events may be considered in determining whether stressors to which the appellant was exposed during service were of sufficient severity as to have resulted in current psychiatric symptoms. Based on the foregoing, the case is REMANDED for the following action: 1. The RO should request that the veteran provide a comprehensive statement containing as much detail as possible regarding the stressor(s) which he alleges he was exposed to during service. He should be asked to provide specific details of the claimed stressful elements during service, including dates, places, detailed descriptions of events, and any other identifying information concerning any other individuals involved in the events or who can corroborate that the events took place. Such identifying information should include names, ranks, units of assignment, or any other identifying detail. The veteran is advised that this information is vitally necessary to obtain supportive evidence on the stressful events and he must be asked to be as specific as possible. He should be informed that, without such details, an adequate search for verifying information cannot be conducted. 2. The RO should request a search of the veteran's service unit records for evidence of the claimed hospitalization for a nervous disorder in Germany during the veteran's service. The RO should contact the SGO and obtain any available hospitalization extracts for the veteran during his period of military service in Germany. An attempt should be made to obtain the operational reports or any other information regarding activities of the veteran's unit in Germany during the time frame cited that would shed light on the events related by the veteran and claimed as stressors. When this information has been obtained, it, together with the stressor information that has been provided by the veteran, should be forwarded to the United States Army and Joint Services Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22150, for verification of the incident or incidents which the veteran claims as stressors. Any information obtained is to be associated with the claims folder. 3. After the above development has been completed, the RO should make a specific determination, based upon the complete record, with respect to whether the veteran was exposed to a stressor or stressors in service, and, if so, what was the nature of the specific stressor or stressors, taking into account any finding of lack of engagement in combat with the enemy and/or lack of corroboration of any claimed stressors unrelated to combat. If the existence of stressors is shown, the RO must specify what stressor or stressors in service it had determined to have been established by the record. In reaching this determination, the RO should address any credibility questions raised by the record. 4. If and only if the RO determines the existence of a stressor or stressors, then the RO should schedule a VA psychiatric examination of the veteran by a Board of two psychiatrists in accordance with VA Physician's Guide to Disability Evaluation Examinations (March 1, 1985). The RO must specify, for the examiners, the stressor or stressors that the RO has determined are established by the record. The examiners must be instructed that only those events may be considered for the purpose of determining the relationship of any PTSD which may be shown to service. If the examiner determines that the veteran has any psychiatric disorder in addition to his previously diagnosed anxiety disorder, the examiner should determine the "relationship of any such disorders among themselves (including etiological origin and secondary causation)," and specify which symptoms are associated with each disorders. The diagnosis should be in accordance with DSM- IV. The entire claims folder and a copy of this REMAND must be made available and reviewed by the examiner prior to the examination. After the requested development has been completed to the extent possible, the RO should again review the record. If the benefits sought on appeal are not granted, the RO should furnish the veteran and his representative a supplemental statement of the case, including a summary of the relevant evidence, citation to the applicable diagnostic codes, and reasons and bases for the decision, and be afforded the opportunity to respond before the record is returned to the Board for further appellate review. The purpose of this remand is to obtain additional development and the Board does not intimate any opinion as to the merits of the case. No further action is required of the veteran until he is notified. BETTINA S. CALLAWAY 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).