BVA9508085 DOCKET NO. 93-10 061 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a psychiatric disorder, to include post-traumatic stress disorder. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from February 1971 to October 1972. This appeal arose from an April 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The RO, in relevant part, denied entitlement to service connection for a psychiatric disorder, including post- traumatic stress disorder. This determination was affirmed in later dated rating decisions. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. REMAND Service connection for post traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). The veteran served as a rifleman with the United States Marine Corps in Vietnam. His decorations include a Vietnam Service Medal w/1*, Vietnam Service Medal with 2 Bronze Stars, Republic of Vietnam Meritorious Unit Citation (Gallantry Cross Medal Color With Palm), Republic of Vietnam Meritorious Unit Citation (Civil Actions Medal, First Class Color With Palm), and Republic of Vietnam Campaign Medal With 1960 Device. VA and non-VA psychiatrists have diagnosed the veteran with post- traumatic stress disorder. These diagnoses all appear to have been based on a history which has yet to be verified. As an examination based on a questionable history is inadequate for rating purposes, West v. Brown, 7 Vet.App. 70, 78 (1994), it is necessary that the veteran be provided an examination where the examiner has the accurate history of the veteran's military service. No verification of his alleged exposure to personal life threatening stressors has been undertaken by the RO. The Board observes that the veteran's psychiatric symptomatology has been variously diagnosed. The representative has requested that an attempt be made to secure the veteran's claimed records of psychiatric treatment dating back to the 1970's. In view of the presence of service records having been misfiled in the veteran's claims folder, the representative requests that the claims file of the other veteran be examined to determine if any of the appellant's records may have been similarly misfiled. The Board notes that the veteran is receiving Social Security benefits. The records pertaining to the award of such benefits have not been associated with the claims file. Therefore, pursuant to VA's duty to assist the veteran in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), the Board will not decide the issue certified for appellate review pending a REMAND of the case to the RO for further development as follows: 1. The RO should contact the veteran and request that he identify any and all health care providers who have provided treatment for psychiatric symptomatology in the 1970's. After obtaining any necessary authorization, the RO should request and associate with the claims file copies of the veteran's complete treatment reports from all sources identified. 2. The RO should examine the claims file of Donald B. Doxsee to determine if any of the appellant's service records may have been associated with his claims file. 3. The RO should contact the National Personnel Records Center and/or other appropriate service department and request the veteran's pertinent personnel records which should be associated with his claims file. 4. The RO should contact the Social Security Administration and request that it furnish photocopies of all medical records pertinent to the veteran's award of disability benefits. If medical evidence utilized in processing such claim is not available, that fact should be entered in the claims file. 5. After obtaining the foregoing requested information, the RO should forward it with copies of the veteran's service medical and personnel records, a copy of the veteran's stressor statement received in August 1992, and a copy of his DD 214 record of service to the Marine Corps Historical Center, Building 58, Washington Navy Yard, Washington, D.C. 20374-0530; and the Commandant of the Marine Corps, Headquarters, U.S.M.C. (Code MMRB), Quantico, Virginia 22134-5030. 6. Following receipt of reports from the above addresses, and the completion of any additional development warranted or suggested by those offices, the RO should prepare a report detailing the nature of any combat action, or inservice stressful event, as verified by the U.S.M.C. If no combat or stressor has been verified, the RO should so state in its report. This report is to be added to the claims folder. 7. Then and only then should the RO schedule the veteran for a VA psychiatric examination by a board of VA psychiatrists, if available, who have not previously examined him to determine whether he suffers from any psychiatric disorder, and if so, its nature, etiology, and severity. The examination is to be conducted in accordance with the diagnostic procedures outlined in the VA Physician's Guide for Disability Evaluation Examinations. All indicated studies including post-traumatic stress disorder psychology evaluation sub scales are to be performed. The examination report should include a detailed account of all pathology found to be present. If there are psychiatric disorders other than post- traumatic stress disorder, the examiners should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be dissociated from one disorder or another, it should be specified. In determining whether or not the veteran has post-traumatic stress disorder due to an inservice stressor the examiners are hereby notified that only the verified history detailed in the reports provided by the U.S.M.C. and/or the RO may be relied upon. If the examiners believe that post-traumatic stress disorder is the appropriate diagnosis they must specifically identify which stressor(s) detailed in the U.S.M.C.'s and/or the RO's report is responsible for that conclusion. The report of examination should include a complete rationale for all opinions expressed. The examiners should assign a numerical score based on the Global Assessment of Functioning Scale (GAF) provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, (3rd. ed., 1987) (DSM-III-R). It is imperative that the psychiatrists include a definition of the numerical code assigned under DSM-III-R in order to comply with the requirements of Thurber v. Brown, 5 Vet.App. 119 (1993). The entire claims folder and a copy of this REMAND must be made available to and reviewed by the examiners prior to their examinations. 8. Following the completion of the foregoing the RO should review the claims file to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination reports to verify that any diagnosis of post-traumatic stress disorder was based on the verified history provided by the U.S.M.C. and/or the RO. If the examiner relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the United States Court of Veterans Appeals has held that a diagnosis of post-traumatic stress disorder, related to service, which is based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. 9. After undertaking any additional development deemed appropriate, the RO should readjudicate the issue of entitlement to service connection for a psychiatric disorder, including post- traumatic stress disorder. If the benefit requested on appeal is not granted to the veteran's satisfaction, the RO must issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. BRUCE KANNEE 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).