BVA9504511 DOCKET NO. 93-01 585 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for bilateral hearing loss and tinnitus. 2. Entitlement to an increased (compensable) evaluation for perforation of the right eardrum. 3. Entitlement to an increased (compensable) evaluation for scars, residuals of a shrapnel wound to the left arm and forearm. 4. Entitlement to an increased (compensable) evaluation for scars, residuals of a shrapnel wound to the left leg. 5. Entitlement to an increased evaluation for post-traumatic stress disorder, evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD James A. Frost, Associate Counsel INTRODUCTION The veteran served on active duty from October 1968 to September 1972. This appeal arises from a rating decision in July 1991 by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Board notes that a rating decision in March 1978 denied entitlement to service connection for hearing loss and tinnitus; the veteran was duly notified of the decision; a timely appeal was not filed and the decision became final. Subsequently, the veteran submitted additional evidence in an attempt to reopen the claim; the RO found that the additional evidence was not new and material and the current appeal on that issue ensued. REMAND In Hood v. Brown, 4 Vet.App. 301 (1993), the United States Court of Veterans Appeals (the Court) stated that the term "definite" in 38 C.F.R. § 4.132 was "qualitative" in character, whereas the other terms used in VA's rating schedule with reference to psychoneuroses were "quantitative" in character. The Court invited the Board to "construe" the term "definite" in a manner that would quantify the degree of impairment for purposes of meeting the statutory requirement that the Board articulate "reasons or bases" for its decisions. 38 U.S.C.A. § 7104(d)(1) (West 1991). In a precedent opinion, dated November 9, 1993, VA's General Counsel concluded that "definite" is to be construed as "distinct, unambiguous and moderately large in degree." It represents a degree of social and industrial inadaptability that is "more than moderate but less than rather large." O.G.C. Prec. 9-93 (Nov. 9, 1993). The Board is bound by this interpretation of the term "definite." 38 U.S.C.A. § 7104(c). In the veteran's case, an issue on appeal is whether post- traumatic stress disorder (PTSD) imposes a "definite" impairment warranting the currently assigned 30 percent disability evaluation, or "considerable" impairment, required for a 50 percent disability rating. The Board is also mindful of the recent finding by the Court that the diagnostic codes under 38 C.F.R. § 4.132 of VA's schedule for rating disabilities do not present a clear basis for describing the degree of impairment imposed by psychoneurotic disorders. Massey v. Brown, No. 93-135 (U.S. Vet. App. Dec. 6, 1994). The Court in Massey directed VA's attention in such cases to the rating schedule's focus on the individual's ability to establish and maintain effective and wholesome relationships with other people and the reduction in initiative, flexibility, efficiency and reliability levels imposed by psychoneurotic symptoms, which results in industrial impairment. In this connection, the Board notes that the multiaxial diagnostic system of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-3rd ed. revised, includes on Axis V a score for "Global Assessment of Functioning" (GAF), which allows a psychiatric practitioner to convey a medical assessment which is relevant to VA's assignment of a disability rating under the criteria set forth in 38 C.F.R. § 4.132. In April 1989, a board of three VA psychiatrists reviewed the veteran's medical records to reconcile the psychiatric diagnoses and relate the veteran's current psychiatric conditions. The board of psychiatrists reported that the veteran had PTSD, delayed onset type. The veteran was hospitalized at a VA medical center from February 1990 to May 1990 for psychiatric treatment. Axis I diagnoses were PTSD and history of alcoholism and substance abuse. No Axis V diagnosis or GAF score was provided. In November 1990 the veteran underwent a VA psychiatric examination. Diagnoses included PTSD, which was characterized as "relatively mild," rendering the veteran only mildly disabled. No Axis V diagnosis or GAF score was provided. A review of the claims folder indicates that the veteran has not had a problem with drug or alcohol abuse since about 1989. In March 1992, a VA clinical psychiatrist reported that the veteran had been attending his PTSD group since August 1990. The psychiatrist stated that the veteran had "a chronic difficulty with the management of startle response and anger escalating into rage. He must be always vigilant to avoid a rage reaction. When he cannot control his anger, fantasy, confusion and explosive rage results. Withdrawal from social contact, including leaving employment, is his only recourse when anger cannot be managed. The intensity of reaction when his symptoms cannot be managed adversely affects his economic adjustment to produce a definite impairment for employment." In June 1992, the psychologist stated that the veteran had "a definite pronounced impairment for employment." The Board notes that in recent years, neither an Axis V diagnosis nor a GAF score has been provided by any physician or by the veteran's treating psychologist. Also, the examining psychiatrist's finding in November 1990 that the veteran was only mildly disabled by PTSD symptoms is in contrast to his therapist's finding in March 1992 of "definite impairment." Furthermore, the Board is unable to determine what the psychologist meant in June 1992 when he said that the veteran had "a definite pronounced impairment for employment." The Board believes that additional medical information is necessary prior to a final disposition of the appeal on the issue of entitlement to an increased rating for PTSD. Accordingly, this case is REMANDED to the RO for the following: The RO should schedule the veteran for psychological testing and for a psychiatric examination by a board of two physicians who have not previously examined or treated him. Psychological testing should include PTSD scales. It is imperative that the psychologist's report and the veteran's claims folder be made available to the board of psychiatrists for review prior to the examination. The board of psychiatrists should determined the nature and current symptomatology of PTSD. They should render diagnoses for each axis on the multiaxial system of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-Third Edition, Revised, including the assignment of a GAF score on Axis V. They should explain how they arrived at the GAF score. Following completion of these actions, the RO should review the evidence and determine whether the veteran's claim of entitlement to an increased rating for PTSD may now be granted, using the definitions of "definite" and "considerable" in 38 C.F.R. § 4.132 provided by O.G.C. Prec. 9-93. If the decision remains adverse to the veteran, he and his representative should be provided with an appropriate supplemental statement of the case and an opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration. The purpose of this REMAND is to obtain clarifying medical information. By this REMAND, the Board intimates no opinion, legal or factual, as to the ultimate disposition of the appeal. Appellate review of the remaining issues on appeal is deferred, pending completion of this REMAND. No action is required of the veteran until he receives further notice. BRUCE KANNEE 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) (1993).