Citation Nr: 0001692 Decision Date: 01/20/00 Archive Date: 01/28/00 DOCKET NO. 98-07 482 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to an increased rating for PTSD, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Jane R. Williams, Attorney at law WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The veteran served on active duty from May 1968 until April 1970. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) from a rating decision of February 1997 of the Chicago, Illinois Regional Office which denied a higher evaluation for the service- connected PTSD. During the pendency of the appeal, the veteran's case was transferred to the Louisville, Kentucky Regional Office (RO). REMAND A review of the record discloses the veteran has not undergone a VA examination for compensation and pension purposes since November 1996. Since that time, clinical reports of record document he has been receiving ongoing treatment for psychiatric symptomatology whereupon fluctuating levels of coping ability have been recorded; from an "excellent mood" in March 1997, to "problematic" PTSD symptoms including ongoing nightmares and general social withdrawal with no friends reported in October 1998. It is shown that he was hospitalized in June 1998 for psychiatric symptoms. The Board is thus of the opinion that a VA examination should be scheduled, to include a social and industrial survey, to more accurately assess the current degree of disability attributable to PTSD and its impact on his social and industrial capability. Additionally, the veteran testified at a hearing before the Board at the local RO, in November 1998, that he received weekly group and/or individual outpatient therapy in the VA outpatient clinic at "Leestown". The record reflects that there has been no updated information in this respect since a clinic note in October 1998 from a VA facility in Lexington, Kentucky was submitted for review. The Board finds that more timely records from the cited VA facility(ies) should be requested and associated with the claims folder. In view of the above, the case is REMANDED to the RO for the following actions: 1. Any and all VA clinical records dating from November 1998 should be requested from the Leestown and Lexington, Kentucky VA facilities and associated with the claims folder. 2. The RO should schedule the veteran for a VA social and industrial survey and special psychiatric examination, in order to determine the extent of the service-connected PTSD. All necessary tests and studies indicated, including psychological testing, should be conducted in order to identify and describe the symptomatology attributable to PTSD. The report of examination should contain a detailed account of all manifestations of the disability(ies) found to be present. If there are found to be psychiatric disorder(s) other than PTSD, the examiner should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be disassociated from one disorder or the other, it should be so specified. The examiner must also comment on the extent to which PTSD affects occupational and social functioning. A multi-axial assessment should be conducted, and a thorough discussion of Axis IV (psychosocial and environmental problems) and Axis V (Global Assessment of Functioning (GAF) score), with an explanation of the numeric code assigned, is to be included. The claims folder and a copy of this remand must be made available to the psychiatrist for review in conjunction with the examination. It should be indicated by the examiner whether the claims folder has been reviewed. The complete rationale for any opinion expressed must be set forth in a legible report. 3. Prior to the examination, the RO must inform the veteran, in writing, of all consequences of his failure to report for the examination in order that he may make an informed decision regarding his participation. 4. The RO should review the examination report to determine if it is in compliance with this REMAND. If deficient in any manner, it should be returned, along with the claims file, for immediate corrective action. 5. After completing any necessary development in addition to that specified above, the RO should readjudicate the claim of entitlement to a disability rating greater than 50 percent for PTSD. If the disposition remains unfavorable to the veteran, the RO should furnish him and his representative with a supplemental statement of the case and afford him the opportunity to respond. Thereafter, the case should be returned to the Board for final appellate review, if in order. The purpose of this REMAND is to ensure compliance with VA's duty to assist. The Board intimates no opinion as to the ultimate outcome of the veteran's claim. No action is required of the veteran until further notice. The appellant 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. U. R. POWELL 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).