BVA9500849 DOCKET NO. 93-07 263 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD M. F. Halsey, Counsel INTRODUCTION The veteran served on active duty from September 1964 to December 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 1992 rating decision that denied service connection for major depression and PTSD. However, a June 1992 letter to the veteran, notifying him of the denial, did not specifically mention the action taken with respect to major depression. Understandably, the veteran thereafter limited his notice of disagreement and arguments on appeal to the question of service connection for PTSD. While the RO has characterized the issue on appeal as entitlement to service connection for a psychoneurosis, to include PTSD, the Board has, in accordance with the veteran's arguments, limited the issue on appeal to entitlement to service connection for PTSD. See 38 C.F.R. §§ 20.201, 20.202 (1993). Although service connection for depression was never claimed by the veteran (see VA Form 21-526 received January 15, 1991), the RO may wish to formally notify the veteran of the denial of service connection for major depression. 38 C.F.R. § 19.25 (1993). REMAND The veteran's representative has requested that further evidentiary development of this case be undertaken. In an April 1993 presentation, the representative argued that a February 1992 VA examination report provided a basis for requiring further evaluation of the veteran. In this report, the VA examiner indicated that the veteran had had a depressive disorder since 1985, but also complained of anxiety and stress symptoms. The examiner opined that the veteran met the criteria for a diagnosis of a "major depressive episode, recurrent type;" however, he felt that further testing was required to clarify the diagnosis. Only provisional diagnoses were provided, and these included conclusions that PTSD, a generalized anxiety disorder, and a personality disorder were yet to be ruled out. Records dated as early as August 1988 show that the veteran complained of having PTSD symptoms. Letters prepared by a private psychiatrist and a VA social worker, dated in September and October 1992, respectively, include opinions that the veteran has PTSD. However, a grant of service connection must be based not only on "medical evidence establishing a clear diagnosis of [PTSD, but on] 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) (1993). In this regard, the Board notes that the assessments of PTSD appear to have been arrived at only on the basis of the veteran's uncorroborated account of what happened during service. Wilson v. Derwinski, 2 Vet.App. 614, 618 (1992) (VA is not required to accept a physician's diagnosis based solely on the veteran's own history). In other words, the requirement that there be "credible supporting evidence that the claimed inservice stressor actually occurred" has not yet been satisfied. § 3.304(f) (emphasis added). It is this sort of corroborating evidence that the representative has asked VA to try to obtain. The veteran has variously claimed that landing in Vietnam with his leg in a cast, being involved in a firefight during a rainstorm, seeing dead and injured, witnessing the traumatic decapitation of a soldier standing nearby, carrying wounded soldiers to treatment, participating in a search and destroy mission, and witnessing a "fragging" were stressful experiences to which PTSD may be attributed. Little detail about any of these events has been elicited from the veteran. He has indicated that his convoy was ambushed on the way to Cu Chi shortly after his unit, part of the 25th Infantry Division, arrived in country (in March 1966); that Cu Chi was overrun about three days after his arrival there; and that the base suffered, for the next five months, repeated breaches of the perimeter and repeated mortar attacks, with many killed or wounded in action within the base itself. Given the assessments made in the September and October 1992 letters, an effort should be made to corroborate the veteran's account of what happened. The lack of development to verify the occurrence of the stressors claimed by the veteran, as well as questions raised by the February 1992 VA examination report concerning the correct diagnosis to be made, lead to a conclusion that further action is required. The Board also notes that the veteran indicated in his appeal that the psychiatrist from whom he is presently seeking treatment, Edward Killeen, M.D., is willing to submit a statement in the veteran's behalf. Records kept by Dr. Killeen may be helpful to deciding this case. Consequently, the case is REMANDED for the following actions: 1. The veteran should be contacted, through his representative, and asked to provide authorization to VA to obtain records kept by Edward Killeen, M.D. Such records, and any statement the veteran may wish to submit from Dr. Killeen should be associated with the claims folder. 2. The veteran should be contacted, through his representative, and asked to provide as much detail as possible regarding each of the claimed stressors, including dates, times, locations, units of assignment, names of others who were involved, and the specifics of each event experienced. 3. The service department should be asked to examine each incident reported by the veteran and provide as much information as possible about the veteran, about others named by the veteran, or about the veteran's unit having been involved in any of the claimed events. The service department should be asked to say whether any additional information is required of the veteran to conduct its research. If so, this should be accomplished. 4. A psychiatrist should be asked to review the claims folder, including information obtained from the service department regarding the occurrence of claimed stressors, and private and VA records. Psychological testing to determine whether the veteran experiences PTSD should also be conducted. The psychiatrist, after reviewing these test results, and the information in the claims folder, should examine the veteran and provide an opinion as to whether the veteran meets the diagnostic criteria for PTSD. Consideration should be given to any evidence which supports the veteran's claims of inservice stressors, or the lack of such evidence. West v. Brown, 7 Vet.App. 70 (1994) (a diagnostic feature of PTSD requires that the sufficiency of the stressor be clinically established). The examiner should provide an opinion as to whether it is at least as likely as not that any currently shown symptomatology is attributable to an inservice stressor. All findings, opinions and bases therefor should be set forth in detail. 5. The RO should take adjudicatory action on the veteran's claim of service connection. If the benefit sought is denied, a supplemental statement of the case should be issued. After the veteran and his representative have been given an opportunity to respond to the supplemental statement of the case, the claims folder should be returned to this Board for further appellate review. No action is required of the veteran until he receives further notice. The purposes of the remand are to procure clarifying data and to comply with governing adjudicative procedures. The Board intimates no opinion, either legal or factual, as to the ultimate disposition of this appeal. J. E. DAY 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) (1993).