BVA9503113 DOCKET NO. 93-10 748 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Francisco, California THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Tresa Schlecht, Associate Counsel INTRODUCTION The veteran had active service from September 1969 to December 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Francisco, California, which following a grant of service connection for PTSD in August 1990, assigned a 30 percent rating following termination of a temporary total hospitalization rating, effective June 23, 1989, through November 1990. Subsequent rating actions extended the temporary total hospitalization rating through February 28, 1991, and assigned a temporary total hospitalization rating from December 10, 1993, through February 28, 1994. In an application submitted in November 1993, the veteran made a claim for benefits on the basis of exposure to Agent Orange. This claim is referred to the RO for appropriate action. REMAND The veteran contends that the 30 percent evaluation of his PTSD does not adequately reflect the severity of his social and industrial incapacitation. He contends that the continued need for treatment, with group sessions and daily self-help group meetings, together with his inability to feel comfortable about anyone who is not also a Vietnam veteran, makes it very difficult to work. The veteran asserts that he has been unemployed since 1987 because of his PTSD, and that, even when employed, he was unable to hold a job for more than a few months at a time because of inappropriate behavior, including aggression and violence, at work. The veteran's representative referred to 38 C.F.R. § 3.340 and it is apparent that the appellant is claiming entitlement to a total disability rating based on individual unemployability. During a hearing held in August 1991, the veteran's representative contended that the severity of the veteran's PTSD and the severity of impairment of his employability should also be considered in light of the veteran's past history of substance abuse, even though the veteran has abstained from drug usage since the time of his hospitalization in 1989. The RO determined that it was not necessary to consider that the veteran's past history of drug abuse in evaluating the severity of his PTSD, since the veteran was no longer using drugs. There are no findings as to whether that condition affects the veteran's social or industrial capacity which respond to the contentions raised by the veteran's representative. After the appeal in this case was perfected, the veteran has again been hospitalized, from December 10, 1993, through February 7, 1994, with a diagnosis of PTSD. Although the RO granted the veteran's claim for a temporary total disability rating during the hospitalization, the RO has not reviewed the 30 percent rating currently in effect for the veteran's PTSD in light of the new evidence regarding the veteran's condition, and has not issued a Supplemental Statement of the Case discussing the new evidence. Accordingly, the case is remanded to the RO for the following actions: 1. The RO should obtain copies of records of the veteran's recent treatment for PTSD, including but not limited to, more complete records of a December 1993 hospitalization at the VA Medical Center in Menlo Park and a hospitalization December 1993 through February 1994 at the VA Medical Center in San Francisco, and records of outpatient followup by the Menlo Park VA Mental Hygiene Clinic. 2. The veteran should be afforded a current VA psychiatric examination in order to determine the severity of his PTSD. All indicated tests and procedures should be performed, including appropriate psychological studies with applicable subscales. The examining physician should describe the relationship between the veteran's PTSD and his past history of substance abuse. The examiner must assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS: DSM-IIIR (3rd ed., revised 1987), and explain what the assigned score represents. If the examiner determines that the veteran's history of substance abuse is a symptom of his PTSD or is secondary to the diagnosis of PTSD, the examiner should objectively relate the history of drug abuse and continued therapy for that condition, to the veteran's social and industrial adaptability, if appropriate, noting whether the veteran has maintained his remission from use of drugs and alcohol, and provide the rationale for any opinion expressed. The claims file must be made available to and reviewed by the examiner prior to the requested study. 3. The RO should adjudicate as part and parcel of the increased rating issue, the issue of entitlement to a total disability rating based on individual unemployability due to PTSD. All development necessary to decide this issue should be accomplished. After the above-referenced development of the claim has been completed, the RO should review the record. In the event that any benefit sought is not granted, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable opportunity to respond thereto. Thereafter, the case should be returned to the Board for further appellate consideration. No action is required of the veteran until he is notified. The Board intimates no opinion as to the ultimate outcome of the case by the action taken above. (CONTINUED ON NEXT PAGE) HOLLY E. MOEHLMANN 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).