BVA9505935 DOCKET NO. 93-15 171 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to an increased rating for a psychiatric disability, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel REMAND The veteran had active service during the World War II era, with additional active service from October 1947 to March 1948 and from March 1951 to July 1954. This appeal arises from a January 1991 rating decision of the San Diego, California, Regional Office (RO), which denied a rating in excess of 10 percent for manic depressive reaction. By a rating dated in October 1991, the RO increased the rating from 10 percent to 30 percent effective from October 2, 1990. The duty to assist includes affording the veteran a thorough and contemporaneous examination that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). This is to ensure that the evaluation of a disability is a fully informed one. The severity of psychiatric disability is based upon actual symptomatology as it affects social and industrial adaptability. See 38 C.F.R. §§ 4.129, 4.130 (1993). The veteran was last afforded a Department of Veterans Affairs (VA) psychiatric rating examination in December 1990. The Board notes that the examiner did not have the veteran's medical records available for review, nor did the examiner provide a Global Assessment of Functioning scale code. In addition, numerous VA outpatient treatment records have been added to the file since the December 1990 examination. The veteran claims that his psychiatric disorder has increased in severity and that in August 1992 he was told by a VA physician that he should no longer work. Taking the foregoing factors into consideration, the Board is persuaded that the veteran should be afforded further VA psychiatric examination in connection with this appeal. VA also has a duty to assist the veteran in the development of other facts pertaining to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals (Court) has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal. The duty to assist is neither optional nor discretionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). The veteran has been receiving continuing treatment for his psychosis at the Loma Linda VA medical center; complete records should be obtained from that facility. Additionally, the veteran was scheduled for appointments with a counselor in the Vocational Rehabilitation Department in order to begin an evaluation for vocational rehabilitation services on more than one occasion during 1991. In March 1992, the veteran submitted another application for vocational rehabilitation. Any counseling records compiled in connection with an evaluation for vocational rehabilitation services should be added to the records assembled for appellate review. Accordingly, the case is REMANDED to the RO for the following actions: 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 Loma Linda VA medical center from December 1992 to the present. Once obtained, all records must be associated with the claims folder. 2. The RO should obtain and associate with the claims folder copies of all records, including any counseling records, compiled in connection with the veteran's application for vocational rehabilitation. 3. Following completion of the above development, the veteran should be afforded a comprehensive psychiatric examination. This study should be conducted in accor- dance with the VA Physician's Guide for Disability Evaluation Examinations. The claims folder must be made available to the examiner prior to the examination. The examiner should review the claims folder in order to obtain a true picture of the progress of the veteran's psychiatric status and in order to integrate current findings with previous diagnoses. Any psychological testing deemed necessary to make a complete diagnostic evaluation and to differentiate symptoms attributable to the service-connected manic depressive reaction (previously classified as dementia praecox, reactive depression, and schizophrenic reaction) from those due to other conditions should be accomplished. If the psychiatric diagnoses include disorders other than manic depressive reaction, the examiner should state whether any other condition is related to the service-connected psychosis or is a disease entity independent of the service-connected psychosis. The examiner should assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual For Mental Disorders, and explain what the assigned score represents. In addition, the examiner should also discuss the impairment of social and industrial adaptability attributable to the veteran's service-connected psychiatric disorder. 4. When the requested development is completed, the RO should readjudicate the veteran's claim. The rating decision should reflect consideration of the applicability of the provisions of 38 C.F.R. § 3.321(b)(1). Unless the claim is granted to the veteran's satisfaction, he and his representative should be furnished with a supplemental statement of the case. They should then be afforded the applicable time 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) (1993).