BVA9503410 DOCKET NO. 93-13 045 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to an increased rating for post traumatic stress disorder (PTSD), currently evaluated as 70 percent disabling. 2. Entitlement to a total rating based upon individual unemployability resulting from service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The appellant and Dr. James Curran ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel REMAND The veteran had active service from January 1968 to January 1970. This appeal arises from a December 1991 rating decision of the Providence, Rhode Island, Regional Office (RO), which denied a rating in excess of 30 percent for PTSD. As the case was developed by the RO, the rating for PTSD was increased to 70 percent and the appeal was expanded to include the issue of entitlement to a total rating based upon individual unemployability resulting from service connected disabilities. The last VA psychiatric examination for rating purposes was in June 1992. The June 1992 VA examination report indicated that the veteran was in receipt of Social Security Administration (SSA) disability benefits; however, the decision granting benefits and the medical records upon which that decision was based have not been obtained. The examiner in June 1992 indicated that Axis I diagnoses included polydrug abuse and that the veteran also suffered from a severe personality disorder which caused distress, problems in interpersonal areas, and inability to maintain employment. The veteran was hospitalized in December 1992 for stabilization of his psychiatric disability as it was noted that he had been having difficulty controlling his anger. The discharge summary included the opinion that the veteran was unemployable. No personality disorder was diagnosed, but Axis I diagnoses included possible bipolar illness in addition to PTSD. In view of the foregoing, the Board is persuaded that the veteran should be afforded a further VA psychiatric examination in connection with this appeal. The veteran has been receiving continuing treatment for his psychoneurosis at the Providence VA medical center; complete records should be obtained from that facility. Accordingly, the case is REMANDED to the RO for the following action: 1. The RO should contact the veteran and obtain the names and addresses of all mental health care providers from whom he has received treatment in recent years. Thereafter, the RO should obtain legible copies of all records which have not already been obtained, to include those from the Providence VA medical center. Once obtained, all records must be associated with the claims folder. 2. The RO should contact the SSA and obtain legible copies of the decision which granted disability benefits to the veteran and the medical records upon which that decision was based. All records should be associated with the claims folder. 3. The veteran should then be afforded a VA psychiatric examination to determine the nature and severity of the manifestations of his PTSD. The claims folder must be made available to the examiner prior to the examination. The examination report should include a detailed account of all pathology found to be present. Primary personality disorders should be fully described and classified. If there are different psychiatric disorders from PTSD, the examiner should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). Any psychological testing deemed necessary to make a complete diagnostic evaluation and to differentiate symptoms attributable to PTSD from those due to other conditions should be accomplished. The examiner should describe how the symptoms of PTSD affect the veteran's social and industrial capacity, and specifically comment on the degree to which the PTSD affects the veteran's initiative, flexibility, efficiency and reliability levels. The examiner should also assign a numerical code under the GAF scale provided in the Diagnostic and Statistical Manual for Mental Disorders and explain the meaning of the numerical code assigned. 4. Following completion of the foregoing, the RO must review the case to ensure that the development has been completed in full and that the report of the psychiatric examination contains data reflecting the degree of reduction in initiative, flexibility, efficiency and reliability levels attributable to PTSD. When the requested development is fully completed, the RO should review the veteran's claims, including the claim that his service- connected disabilities preclude employment. The rating decision should reflect consideration of all potentially applicable criteria, to include consideration of the applicability of 38 C.F.R. § 3.321(b)(1). If the decision remains adverse to the veteran in any way, he and his representative should be furnished with a supplemental statement of the case which summarizes the pertinent evidence and reflects detailed reasons and bases for the decision. They should then be afforded the applicable time period to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. GARY L. GICK 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 deter- mination. 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).