BVA9507865 DOCKET NO. 93-15 110 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION The veteran served on active duty from September 1966 to September 1968. This appeal arises from rating determinations of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. REMAND The veteran has submitted a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). As his claim is plausible and capable of substantiation, the VA has a duty to assist him in the development of facts pertinent to his claim. Murphy v. Derwinski, 1 Vet.App. 78, 81-2 (1990); 38 C.F.R. § 5107(a) (1994). A review of the record shows that service connection for post- traumatic stress disorder (PTSD) was granted in a rating decision of June 1991. A noncompensable evaluation was assigned. That decision was appealed, and the Board of Veterans' Appeals (Board) granted a 10 percent rating in a May 1992 decision. This determination was promulgated by the RO in a June 1992 rating action. VA outpatient treatment records dated from December 1991 through March 1993 are of record. These records show treatment for numerous disabilities to include PTSD. In February 1992, it was noted that the veteran still complained of poor sleep and nightmares. In October 1992, it was noted that he had run out of medication for his psychiatric disorder approximately two weeks earlier. The veteran related that he was under less pressure as his children were back in school. In December 1992 and January 1993, he reported that he still experienced disturbing nightmares about his time in Vietnam. In February 1993, he reported severe headaches, and he said that he experienced nightmares on the average of one or two times per week. He would wake up with sweats even if the room was cold and then was unable to fall back asleep. He felt a "lot of anger." In March 1993, his mood was described as dysphoric and his affect was flat. In a June 1993 statement, the veteran's representative argued that the evidence showed that the veteran warranted a rating in excess of 10 percent for PTSD. In support of this contention, he stated that the record showed a current and continuing problem with stress involving his wife and children. In a statement dated in January 1994, the representative pointed out that the veteran continued to take medication in an effort to ameliorate psychiatric symptomatology. The representative added that the evidence showed that the appellant continued to have difficulty with nightmares, depression and sleep disturbance. It is apparent that the veteran has received a significant amount of psychiatric treatment since his examination in May 1991 and because the record is equivocal as to the current level of social and industrial impairment associated with PTSD, it is concluded that further development is appropriate. Accordingly, the claim is REMANDED for the following: The RO should schedule the veteran for a comprehensive VA psychiatric examination. This study must be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, must be conducted. The claims file must be made available to and reviewed by the examiner prior to the requested study. The examiner must assign a Global Assessment of Functioning (GAF) Score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (3d ed. rev., 1987), and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. Following completion of the foregoing, the RO must review the claims folder and ensure that the development has been conducted and completed in full. If the development is incomplete, appropriate corrective action is to be implemented. When the development is satisfactorily completed, the additional evidence should be reviewed by the RO. Should the veteran remain dissatisfied with the determination, the case should be returned to the Board in accordance with the usual appellate procedures, to include the issuance of a supplemental statement of the case to the veteran and his representative. No action is required of the veteran until he receives further notice. The purpose of this REMAND is to obtain additional information and to ensure compliance with due process considerations. THOMAS J. DANNAHER 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 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).