Citation Nr: 0000147 Decision Date: 01/05/00 Archive Date: 12/28/01 DOCKET NO. 94-11 768 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an evaluation in excess of 50 percent for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD R. A. Caffery, Counsel INTRODUCTION The veteran served on active duty from May 1969 to May 1971. By a rating action dated in May 1993, the Department of Veterans Affairs (VA) Regional Office Indianapolis, Indiana, granted service connection for post-traumatic stress disorder and assigned a 10 percent evaluation for that condition. The veteran appealed for a higher evaluation for the post- traumatic stress disorder. In a May 1994 rating action, the evaluation for the post-traumatic stress disorder was increased from 10 percent to 50 percent. The case is now before the Board for appellate consideration. REMAND The records reflects that the veteran's initial claim for service connection for post-traumatic stress disorder was submitted in January 1993. When the veteran was examined by the VA in April 1993, it was indicated that he was currently unemployed and had been receiving Social Security disability benefits for a number of years. The disability benefits resulted from a back injury sustained in a construction accident. The veteran described various traumatic events occurring in Vietnam. He also dated his substance abuse to Vietnam. He reported dreaming once or twice a week and awakening in a sweat and being unable to go back to sleep. He felt detached and estranged from other people and had a sense of a foreshortened future. He complained of irritability, difficulty concentrating, and hypervigilance. He reported that he had much difficulty with his temper and also had sporadic episodes of homicidal ideation which he had not acted upon. The veteran was again examined by the VA in April 1994. The veteran reported nightmares 3 or 4 times a week, diminished interests and social life, difficulty staying asleep, irritability, an exaggerated startle response and hypervigilance. When the veteran was examined by the VA in August 1996, he reported anger, recurring dreams of Vietnam and irritability. On mental status examination, he appeared to be worried and his affect was restricted. He was alert and oriented as to person, place and time. His memory was intact. His concentration was intact. His judgment was considered poor by history. He claimed that he had not used any drugs for the previous four years and was attending support groups. The degree of psychiatric impairment was reported to be moderate. A global assessment of functioning (GAF) score of 35 was assigned. When the veteran was seen in September 1996, it was indicated that he had dreams about his Vietnam experiences at least twice per week. He became angry and hostile. His affect was flat. He had poor insight and judgment. A current GAF of 30 was assigned. In a report by Gregory V. Richardson, M.D., a psychiatrist, dated in September 1997, it was indicated that the veteran was extremely hypervigilant. He was cooperative, although very guarded while answering questions. His mood was suspicious but pleasant. There was no evidence of delusions or hallucinations, but severe paranoia was evident. Dr. Richardson indicated that the current evidence supported a much higher disability rating than 50 percent. He considered the veteran as meeting the VA requirements for a total disability rating. A GAF score of 35 was assigned. The veteran was afforded a VA examination in October 1998. It was noted that he had sustained a fall in 1986 with multiple massive traumas and had not worked since that time. He reported that he had been off drugs and alcohol since 1992 and was taking drug classes. He complained of sleeping very poorly. He reported experiencing episodes of rage. He had dreams once or twice a week. He had symptoms of increased arousal and difficulty concentrating and irritability. The diagnosis was post-traumatic stress disorder. The GAF score was 70. Since the veteran has maintained that his psychiatric condition is more severe than the evaluation of 50 percent represents, the Board concludes that he has submitted a well- grounded claim for an evaluation in excess of 50 percent for his post-traumatic stress disorder. Drosky v. Brown, 10 Vet. App. 251 (1997). The VA, accordingly, has a duty to assist him in the development of his claim. In this regard, in view of the wide discrepancy between the GAF scores of 30 to 35 assigned on the VA examination and outpatient treatment records in 1996 and by the private psychiatrist in 1997 and the score of 70 reported on the most recent VA examination in October 1998, the Board believes that additional medical evidence would be desirable. Accordingly, the case is REMANDED to the regional office for the following action: 1. The VA Medical Center, Indianapolis, should be contacted and asked to provide copies of all outpatient records reflecting treatment of the veteran for his post-traumatic stress disorder since September 1996. Any such records obtained should be associated with the claims file. 2. A social and industrial survey should be conducted for the purpose of developing collateral information regarding the veteran's daily activities, behavior, social integration and any efforts at obtaining employment. 3. The veteran should then be afforded a special psychiatric examination in order to determine the current nature and severity of his post-traumatic stress disorder. All indicated special studies should be conducted. The examiner should assign a GAF score and explain what the assigned score represents. The claims file is to be made available to the examiner for review prior to conducting the examination. 4. The veteran's claim should then be reviewed by the regional office. If the denial is continued, he and his representative should be sent a supplemental statement of the case and be afforded the appropriate time in which to respond. When the above action has been completed, the case should be returned to the Board for further appellate consideration, if otherwise in order. No action is required of the veteran until he receives further notice. The purpose of this REMAND is to obtain clarifying information. The Board intimates no opinion as to the disposition warranted in this case pending completion of the requested action. ROBERT D. PHILIPP Member, Board of Veterans' Appeals 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) (1999).