Citation Nr: 0002165 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 94-48 335 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated 50 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant REMAND The veteran served on active duty from June 1943 to January 1946. This appeal arose from an October 1994 decision by the Chicago, Illinois, Department of Veterans Affairs (VA) Regional Office (RO). Following a hearing before the undersigned Acting Member of the Board of Veterans' Appeals (Board), the veteran's claim was remanded in order to secure additional medical records. A VA psychiatric examination of the veteran was conducted in February 1999 at the request of the RO. In the examination report the diagnoses were reported to be early onset dementia with depressed mood, post-traumatic stress disorder and depressive disorder. The examiner assigned a Global Assessment of Functioning (GAF) score of 38 and indicated that the symptoms were based on all the disorders and that there was no way to separate the symptoms. While in the examination form it was requested that the examiner, if unable to separate the symptomatology, explain why, no such explanation was given. The Board notes that, as the examination report was completed on a form used to report the findings made on an examination for the purposes of determining whether a veteran has post- traumatic stress disorder and not one for the purpose of reporting an examination of a veteran claiming an increased evaluation for post-traumatic stress disorder, the findings reported are limited when compared to earlier VA psychiatric examinations. The record also shows that the VA psychiatric examination preceded the securing of the medical records and the examiner was not given the opportunity to evaluate these records. The Board has determined that the issue must be REMANDED to the originating agency for the following action: 1. The RO should contact the veteran and request that he provide the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for service-connected post-traumatic stress disorder since May 1998. With any necessary authorization from the veteran, the RO should attempt to obtain copies of these records not included in the current claims file. 2. Upon completion of the above, the RO should schedule the veteran for a special VA examination by a Board of two psychiatrists to determine the extent of his post-traumatic stress disorder. All necessary tests and studies should be accomplished, and all clinical manifestations should be reported in detail. The examiners should report a multi-axial diagnosis, identifying all current psychiatric disorders. The examiners are requested to identify those symptoms, to the extent possible, which are manifestations of the veteran's service-connected post-traumatic stress disorder and should indicate, with respect to each of the psychiatric symptoms identified under the new schedular criteria for rating mental disorders, whether such symptom is a symptom of the veteran's service- connected post-traumatic stress disorder. They are requested to proffer an opinion as to the extent to which the veteran's service-connected post-traumatic stress disorder interferes with his ability to establish and maintain relationships as well as the reduction in initiative, efficiency, flexibility and reliability levels due to his post-traumatic stress disorder. A complete rationale for all opinions expressed must be provided. The examiners should indicate the veteran's overall psychological, social, and occupational functioning using the GAF scale provided in the Diagnostic and Statistical Manual of Mental Disorders. The claims file, including a copy of this REMAND, should be made available to the examiners before the examination, for proper review of the medical history. The examination report is to reflect whether such a review of the claims file was made. 3. Upon completion of the above, the originating agency should review the veteran's claim for an increased evaluation for post-traumatic stress disorder for the period previous to November 7, 1996, by considering the regulations pertaining to the rating of psychiatric disorders which were in effect previous to that date. For the period beginning November 7, 1996, both the regulations pertaining to the rating of psychiatric disorders which became effective November 7, 1996, as well as the regulations pertaining to the rating of psychiatric disorders which were in effect previous to November 7, 1996, should be considered and the regulations more favorable to the veteran should be applied. If any determination made is unfavorable to the veteran, a supplemental statement of the case should be provided to the veteran and his representative. They should be afforded the appropriate period of time in which to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. No action is required by the veteran until he receives further notice. The purpose of this REMAND is to secure clarifying information. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. HILARY L. GOODMAN Acting Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 1999), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (1999).