BVA9506343 DOCKET NO. 93-09 737 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Ehrman, Associate Counsel INTRODUCTION The veteran served on active duty from March 1980 to October 1980. The appeal comes before the Board of Veterans' Appeals (the Board) from a December 1991 rating decision of the Lincoln, Nebraska, Regional Office (the RO) of the Department of Veterans Affairs (the VA). That determination denied service connection for PTSD, as well as dysthymic disorder, major depressive disorder, generalized anxiety disorder and mixed personality disorder. In her December 1992 substantive appeal, the veteran indicated that she wanted to have the reason for her discharge, presumably from service, changed. She is advised that this matter is not within the jurisdiction of VA and that she should contact the appropriate service department. REMAND The veteran was recently afforded two VA psychiatric examinations, in June and July 1992. Although the VA examination of July 1992 attempted to clarify the June 1992 VA diagnosis of "possible" PTSD, the Board finds that an additional VA psychiatric examination of the veteran is required, in light of her other multiple psychiatric diagnoses and the absence of an opinion concerning any relationship between service and current psychiatric disability. In essence, the veteran contends that psychiatric disability was incurred in or aggravated by service. Specifically, she contends, in part, that she acquired psychiatric disability, to include PTSD, as a result of a May 1980 rape which occurred during service. In support of her contention, the veteran has submitted a local civilian police complaint report of July 1980, which indicates the facts and circumstances of the alleged incident. Service medical records include a July 1980 narrative summary which also indicates similar complaints resulting from an alleged rape. The veteran's initial VA Application for Compensation or Pension, received at the RO in December 1990, claims entitlement to service connection for "major depression." The veteran's claims file discloses that multiple psychiatric diagnoses have been entered. A private hospital discharge summary, dated in October 1989, indicates a history of severe depression since childhood, with a current diagnosis of major depressive disorder without psychosis, and dependent personality disorder. A VA examination of January 1991 indicates additional psychiatric diagnoses to include dysthymic disorder with possible major depressive episode, generalized anxiety disorder, PTSD, and mixed personality disorder with dependent and avoidant features. A private medical statement of April 1991 indicates recent treatment for chemical dependency stemming from childhood emotional and physical abuse. Private hospital summary reports, for treatment received from March to May 1992, indicate a principal diagnosis of schizoaffective disorder, chronic, with acute exacerbations, and secondary diagnoses were substance abuse, PTSD, and self-mutilative disorder, by history. In Waddell v. Brown, 5 Vet.App. 454 (1993), the United States Court of Veterans Appeals (the Court) held that there may be a breach in the duty to assist when there are variously diagnosed psychiatric disorders, but none of the examinations fully described the degree of disability attributable to each psychiatric disorder. In this case, the Board may be presented with service-connected and nonservice-connected psychiatric disorders. The origin or onset of each and every psychiatric disorder has not been determined, and the degree of impairment attributable to each has not been identified, and fully determined. The Board notes that service medical records include a February 1980 Report of Medical History, taken at the time of the veteran's entrance into service. This report indicates "[f]requent trouble sleeping," "[d]epression and excessive worry," and "[n]ervous trouble of any sort." The examiner noted, in pertinent part, that her medical history was significant for "[n]ervous[ness]." Psychiatric evaluation at that time, however, was noted to be normal. Service medical records also indicate that in July 1980, the veteran was admitted to the psychiatric ward for intermittent "nervousness and anxiety," and the diagnosis of "transient situational reaction" was given. However, the RO, in developing the veteran's claim, has failed to adequately address the issue of entitlement to service connection for an acquired psychiatric disability, based upon the aggravation of a pre-existing injury suffered or disease contracted in the line of duty, under 38 U.S.C.A. § 1131 (West 1991). The Board is also of the opinion that additional pertinent records may exist that have not been associated with the claims file. While the veteran has submitted a copy of the July 1980 civilian complaint report originally filed with the Orange County, Florida, Police Department, the Board is of the opinion that the RO should attempt to obtain any additional records regarding any investigation or resolution of her July 1980 complaint. The Board is satisfied that the RO has obtained copies of all additional private treatment records specifically referred to by the veteran. However, the veteran recently submitted an October 1994 award letter from the United States Department of Health and Human Services, Social Security Administration (SSA), effective in June 1990, indicating severe impairment resulting from schizoaffective disorder, recurrent major depression, severe panic disorder with agoraphobia, PTSD, dependent personality disorder, borderline personality disorder, and self-mutilative disorder. This evidence has not been considered by the RO, nor has the veteran waived such consideration. The clinical records upon which the decision was based have not been associated with the claims file. Accordingly, the RO should obtain copies of any psychiatric treatment records, not already of record, that were utilized by the SSA in making their favorable determination of her disability compensation claim with their office. The Court has held that the duty of the VA to assist veterans in the development of facts pertinent to their claims, under 38 U.S.C.A. § 5107 (West 1991) and 38 C.F.R. §§ 3.103 and 3.159 (1993), as set forth by the Court in Littke v. Derwinski, 1 Vet.App. 90 (1990), requires that the VA accomplish additional development of the record if the record currently before it is inadequate. In view of the foregoing, and in accordance with the duty to assist the veteran in the development of her claims mandated by 38 U.S.C.A. § 5107 (West 1991), this case is REMANDED for the following: 1. The RO should request that the veteran provide the names and addresses of all health care providers, physicians and psychiatrists who have treated her for psychiatric or mental disorders from her childhood to the present, especially concerning any treatment received from June 1992 until the present. The RO should also request that the veteran provide appropriate authorizations for the release of any and all records, not already contained in the claims file, pertaining to such treatment, including authorizations for the release of any and all medical and psychiatric records from the United States Department of Health and Human Services, Social Security Administration, and the Orange County, Florida, Police Department, regarding complaint #80-072722, dated July 8, 1980. 2. Upon the receipt of any names and addresses of health care providers identified by the veteran as having treated her, and authorizations for the release of records pertaining thereto, the RO should request that all health care providers identified by the veteran furnish the RO with legible copies of all records pertaining to their treatment of the veteran, if not already contained in the claims file, including copies of all treatment records pertinent to the appellant's claim for Social Security disability benefits as well as the medical records relied upon concerning that claim. 3. Upon the completion of the above requested developments, the veteran should be scheduled for a VA psychiatric examination. All indicated tests and studies should be performed, and the claims folder must be made available to the examiner for use in the study of the case. A definitive diagnosis should be entered, with indication of the etiology and onset of any and all psychiatric diagnoses entered, including: Major depressive disorder; dependent personality disorder; dysthymic disorder; chemical dependency and alcohol abuse; generalized anxiety disorder; PTSD; mixed personality disorder; schizoaffective disorder; and self-mutilative disorder, if found to exist. If either chemical dependency or alcohol abuse is diagnosed, the examiner is to provide a detailed description of the relationship between the substance abuse and PTSD or any other acquired psychiatric disability, if found to exist. The examiner should provide an opinion as to the medical probability that any psychiatric disorder currently present had its onset during military service or is otherwise related thereto. The examiner is to set forth all findings and conclusions, along with rationale and support for the diagnosis entered, in a clear, comprehensive and legible manner, with reference to supporting evidence. 4. Thereafter, the RO should readjudicate the issue of entitlement to service connection for an acquired psychiatric disability, to include PTSD. Furthermore, the RO is to develop and adjudicate the above issue with consideration of the laws and regulations pertinent to service connection for the aggravation of a pre-existing disability, under 38 U.S.C.A. § 1131 (West 1991) and pertinent law and regulations. If the decision, in whole or in part, remains adverse to the veteran, she and her representative should be provided a supplemental statement of the case, as to any issue to which a notice of disagreement has been provided, and the veteran and her representative should be afforded an opportunity to respond thereto. Evidence recently submitted and not previously considered should be reviewed. Thereafter, if indicated, the case should be returned to the Board for appellate consideration. The Board intimates no opinion as to the ultimate outcome of this case. No action is required on the veteran's part until further notice. BARBARA B. COPELAND 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).