BVA9505038 DOCKET NO. 93-11 227 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for a psychiatric disorder. 2. Entitlement to service connection for a sinus disorder. REPRESENTATION Appellant represented by: Disabled American Veterans INTRODUCTION The veteran served on active duty from January 1979 to August 1985. This appeal arises from an October 1991 rating decision of the Buffalo, New York, Department of Veterans Affairs (VA) Regional Office (RO). REMAND The veteran contends that service connection for a psychiatric disorder is warranted on either a direct or secondary basis. In this regard, the appellant asserts that while on active duty in the Federal Republic of Germany and at Fort Hood, Texas, she received regular outpatient psychotherapy, including psychiatric medications. She urges that an attempt be made to secure her treatment records directly from the involved medical centers. With respect to her assertion that secondary service connection is warranted the veteran argues that her current psychiatric disorder is a direct result of her service connected residuals of salpingitis, with secondary infertility, status post tubal surgery. A review of the service medical records reveals no complaints or findings pertaining to a psychiatric disorder. A review of the post service record, however, reveals that the appellant has been diagnosed with an adjustment disorder, a dysthymic disorder, and, at times, post traumatic stress disorder. Moreover, the veteran has provided a history concerning certain stressful events which purportedly occurred during her active duty service, and the post service clinical records do make reference to the appellant’s receipt of psychiatric care within one year of her separation from active duty. Accordingly, because no effort has been made to verify the veteran’s "stressors," and as no attempt has been made to gather the clinical evidence which the appellant has reported to be in the government’s custody, further development is warranted. Further development is also required in view of the veteran’s apparent service in a reserve component following her separation from active duty. While neither of the claims for service connection involve direct physical injuries, the records maintained by the veteran’s reserve until may provide pertinent evidence which should be considered prior to reaching a final determination. Accordingly, this case is REMANDED for the following action: 1. The RO should contact the 409th PSC located at 2393 Colvin Boulevard, Tonawanda, New York 14150, and request that they verify any reserve service the veteran may have performed with their unit, and provide photocopies of any service medical records which they may have in their possession. 2. The RO should contact the veteran and request that she identify any health care provider in Lockport, New York from whom she purportedly received treatment for a psychiatric disorder beginning in 1985. Thereafter, the RO should undertake appropriate development. 3. The RO should also request that the veteran provide additional information concerning the alleged stressful events during her active duty service. Specifically, the appellant should provide the dates she served with the 379th PSC in Heidelberg, Germany; the dates and the units with which she served in Nuremberg, Germany, and Ft. Hood, Texas; and the dates and the units with which her husband and any alleged assailant served at any time during her term of active duty service. The name of any alleged assailant should also be provided. 4. The RO should contact the National Personnel Records Center and request that they provide a photocopy of the veteran’s service personnel record ("201 file"), and any additional service medical records which they may have in their possession. 5. Following the receipt of the appellant’s response, and the completion of any necessary development, the RO should provide the information submitted by the veteran concerning certain alleged assaults by her former husband and other soldiers, as well as a copy of her service personnel records, to the United States Army and Joint Services Environmental Support Group (ESG) 7798 Cissna Road, Springfield, Virginia 22150. Upon receipt, the ESG is requested to examine any pertinent unit reports, courts martial records, disciplinary proceedings, and/or administrative proceedings in an effort to verify the stressful events claimed by the veteran. 6. Following the receipt of the ESG’s, and the completion of any necessary followup development, the RO should prepare a report detailing the nature of any stressful event verified by the ESG. If no event could be verified the RO should so state in their report. This report is then 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 psychiatrist who has not previously seen or treated her. This examination is to be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations in order to determine the nature and extent of any psychiatric disorder which may be present. All indicated studies, including post-traumatic stress disorders sub scales, are to be performed. The claims file must be provided to and reviewed by the examiner prior to conducting this examination. If a psychiatric disorder is diagnosed, the examiner is requested to offer an opinion whether it is at least as likely as not that the disorder is due or the result of her service connected residuals of salpingitis, with secondary infertility, status post tubal surgery. If the examiner believes that PTSD is the appropriate diagnosis the examiner is notified that only the verified history detailed in the reports provided by the ESG and/or the RO may be relied upon, and the examiner must specifically identify which stressful event detailed in the ESG and/or the RO's report is responsible for that conclusion. All opinions expressed must be accompanied by a complete rationale. 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 report to verify that any diagnosis of PTSD was based on the verified history provided by the ESG 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. In this respect the Board observes that the United States Court of Veterans Appeals has held that a diagnosis of PTSD based on an examination which relies upon an unverified history is inadequate for rating purposes. West v. Brown, 7 Vet.App. 70, 77 (1994). 9. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for a psychiatric disorder, and a sinus disorder. The issue of entitlement to service connection for a sinus disorder is deferred. If the benefits sought on appeal is not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be provided. Thereafter, the case should be returned to the Board, if otherwise in order. By this REMAND, the Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action until she is otherwise notified. DEREK R. BROWN 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). The Board acknowledges that the RO in September 1985 did contact the reserve un appellant’s discharge orders. No attempt, however, has been made since. As the served with the reserves for two years following her separation from active duty warranted.